The New Government must prioritise strengthening of Primary Health Care to achieve Universal Health Coverage and the Sustainable Development Goals
Now that the elections are over, the people of Zimbabwe expect the fulfilment of the election manifesto, in which you promised massive improvement in health infrastructure; more health personnel; accessible and affordable medicines; free medical care for cancer patients; at least one hospital per district, improved health services in resettlement areas, reduction of hospital fees by 50% and pursuing the Health for All policy, among others.
As Community Working Group on Health (CWGH), we summarize this as primary health care with clear intentions for the attainment of Universal Health Coverage (UHC) and therefore the ustainable Development Goals (SDGs).
For this reason, the CWGH network would like to urge the government to immediately shift focus to real developmental issues, particularly taking into account the dire need of improving health service provision for the benefit of ordinary Zimbabweans as articulated in the pre-elections.
It is undeniable that the deplorable state of the country’s health system requires urgent attention, especially giving priority focus to revitalizing the PHC system and addressing the social determinants of health to achieve UHC, thus enabling every Zimbabwean equitable access to essential quality health services without facing financial hardships. Zimbabwe need sustained investments in primary health care to revitalise the health system to close gaps in access to services and to address the causes of ill health.
Presenetly, infrastructure in hospitals is dilapidated, some is obsolete; medicines and supplies are in short supply; doctors, laboratorians, pharmacists, paramedics and nurses are inadequate and poorly motivated. And this against a background of sustained paltry funding to the sector from national fiscus is of major concern.
The problems in the health sector are compounded by the very high prevalence of largely preventable diseases as well as behaviour, lifestyles, environmental and basic water and sanitation issues.
The quadruple burden of disease, (communicable, non-communicable, injuries, HIV, maternal, peri-natal, neglected tropical diseases, cancers) is unmatched by the institutional and health staff skills to adequatey manage and these have individually or in combination translated into premature and excess mortalities across the ages.
Therefore, the health system must be strengthened in accordance with the World Health Organization’s six building blocks and the over ambitious SDG targets, to respond to this huge burden of disease, and enable the country to reach its full developmental trajectory.
In recent years, many countries have adopted UHC as national policy priority and have committed to directing government funding towards that goal.
Ensuring sustainable progress toward UHC means that Zimbabwe’s public health financing
system must routinely generate sufficient, and largely domestic, resources to achieve health sector objectives within its macroeconomic and fiscal context. It is not only the level of government health spending that matters for sustaining health systems that can meet UHC goals, but also the efficient and equitable use of those funds.
Public budget revenues, as well as the public financing systems that manage those funding flows, therefore play a crucial role in directing money efficiently, equitably and effectively towards UHC goals and other health priorities.
This year marks forty years after the 1978 Declaration of Alma Ata on Primary Health Care which inspired and galvanized understanding, analysis and action on health. In our region, and indeed in this country, the aspirations and content that were included in the 1978 declaration were embedded into liberation movement goals and post independence policies and informed the organisations and transformation of health services.
This largely informed the early adoption of the PHC concept and philosophy at independence and just 2 years post Alma Ata and the subsequent policies on health for all saw Zimbabwe achieving remarkable health indicators just 10-15 years post-independence and assuming a health leader position in the African region.
As CWGH we see a semblance of the same energy, and are therefore hopeful that the new leadership will take us from Alma Ata, to the Millennium Development Goals (MDGs), to Abuja and all the way to the SDGs within the next 5 years.
We are hopeful that the new dispensation will go well beyond the appending of signatures to declarations, but revisit the various declarations over the past 40 years, and carry forward what worked but critically analyze why we fell short of health goals and thus sent a significant number of Zimbabweans to ill health, disability and early graves, when all these could be avoided.
Zimbabwe needs a renewed commitment to health and well-being for all based on UHC and should locate PHC as a necessary foundation to achieve UHC. Our focus is thus on UHC as the end and PHC as the means.
We call for an economic order that would serve the attainment of health and reduce inequalities in health nationally, while also recognizing that the promotion and protection of people’s health in both public and private sectors is essential for socio-economic development.
The CWGH strongly reaffirms the full definition of health as articulated at the formation of the WHO that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.
The CWGH calls on the new government to urgently address the proximal determinants of the health of all Zimbabweans including but not limited to shortage of health personnel by unreservedly lifting the freeze on employment of health staff, and rationalizing the balance of clinical and support staff. We are energized by the new board at the helm and sincerely hope that the Health Services Board (HSB) hit the ground running.
The new board must address the glaring management and governance issues and ensure that the employer of choice for all health workers is central government as obtained in the past. Managing a professional workforce requires skill and capacity that we find missing in the public health sector and this largely accounts for the mass exodus of our highly trained health workers to offer their young productive lives elsewhere.
Furthermore, these workers require the tools of the trade, which in turn must be effectively and efficiently managed, be they infrastructure, medicines, equipment, ambulances, service vehicles, and new technologies to make their work less tedious than it currently is.
However, all this can be achieved if the government increases national budgetary funding for the health sector, which also comes with fixing the current constipated economic fundamentals.
We wish to remind the new government that Zimbabwe has never achieved the 15% Abuja target since the declaration was signed in 2001, and to also point out that the target then was to ensure at least 60% access to specific populations in the country to access maternal and child health, AIDS, TB and malaria, services which such as plaster, wound care, the capacity at local level may not be there.
This means Zimbabweans are being denied their right to health although Section 76 of the Constitution clearly states that: “Every citizen and permanent resident of Zimbabwe has the right to have access to basic health care services, including reproductive health-care services”.
To this end we implore you, Your Excellency and the new government to take heed of the WHO’s six building blocks of an effective health delivery system, whereby the services need to be tailored to the needs of specific population groups. Many public health programmes do not have or are not reaching their health equity goals because they not only lack specific interventions but also fail to reach marginalized populations.
In Zimbabwe, community health structures exist to assist in health promotion and provision of health services. We have supported governance structures from the Health Centre Committees, District Mnagement Teams and the Public Health Advisory Board, and the Parliamentary Portfolio Committee on Health at national level.
However, as the country embraces SDGs and therefore UHC, there has to be a policy on integration and movement from the programme and donor-based approach to health programming to a comprehensive and nationwide coverage of health interventions. Community-Based Workers — Village Health Workers, Community Based Distributors, Home Based Care Workers, Youth and Women’s Affairs and Envirnmental Health Technicians — must all be trained in both UHC and the SDGs for full community participation in health and development agenda.
We therefore urge the govermnet to fundamentally support and strengthen the role of local leadership and community structures for health interventions to bear fruit. It is risky and unsustainable for a country to depend substantially on external partners as donors can withdraw financial support anytime should their interests shift for some reasons.
The Paris Declaration on aid effectiveness refers. None of the donors have kept their part of the bargain, none have nationwide reach and this is why our health indicators have plummeted over the years.
Despite these shortcomings from the donor community, presently, about 90% of medicines used in
the public health delivery system in Zimbabwe are funded by donors, a national security threat should the external partners pull the plugs.
This also says a lot about how far we are as a country from fully embracing PHC and therefore our progress towards UHC. Your new government, Your Excellency, therefore needs to design and implement new and innovative domestic health financing policies to fund a strengthened primary
health care strategy to achieve UHC.
We have over the years proffered several options and strategies that Zimbabwe can explore for innovative mobilization of resources building on best practices in global health financing to boost public spending on health without undermining fiscal sustainability.
These include decentralisation and devolution with increased transfers from the central government to local governments and peripheral health facilities on the basis of needs and performance as well as the establishment of a mandatory national health insurance system including cross-subsidies from richer to poor categories.
To this end we implore you, Your Excellency to continue the Diaspora engagement you started under ”Zimbabwe is open for business” in bringing back remittances in support for the revitalization of the health delivery system and the technical expertise through mentorships and skills transfer programme to strengthen the same system that was weakened by their departure. This calls for heightened management and governance capacity at the national and sub-national levels for accountability, transparency but also importantly effectiveness and efficiency in utilizing the mobilized financial, other material and human resources.
CWGH believes that addressing the country’s onerous health challenges requires total political commitment to implementing the primary health care concept to achieve universal health coverage to ensure that every Zimbabwean enjoys his/her right to health.
The people’s hopes and health aspirations lies in the new administration.
Remember, you will be judged by what you promised, Your Excellency, but we stand ready to continue working with you and with all well-meaning Zimbabweans towards our shared goal of achieving UHC and the SDGs.
This letter was written by Itai Josh Rusike in his capacity as the Executive Director for Community Working Group on Health (CWGH)