Key Sector Priorities and Considerations
 Raising domestic public funds is essential for universal health coverage (UHC). No
country has made significant progress toward UHC without increasing reliance on
public revenues. Therefore, domestic tax systems that are essential to support country’s
fiscal space expansion are central to the UHC agenda.
 Ensure the allocation of at least 15% of the National Budget to health care in line with
the Abuja Declaration target. Importantly, the Government must implement the Health
Financing Policy and Strategy.
 Prioritise primary health care for the achievement of universal health coverage and
national development targets, especially that of an empowered upper middle-income
economy. Primary health care is the frontline of Zimbabwe’s health system, as
enshrined in all the health strategic plans and on the Ministry logo. A strong, wellfunded and accessible primary health system keeps people healthier and out of hospital
by supporting them to manage their health issues, including chronic conditions, in the
community, while also accessing referrals and specialist services whenever needed.
This reduces Zimbabweans’ reliance on costly acute care, such as specialists,
emergency departments or other hospital services. It’s therefore vital to revitalize
primary health care implementation and specifically budget for primary health care.
 Strengthen the national referral, provincial, district, health facility and community
systems/centres and the health governance mechanisms at each level. The district and
community health systems are the foundation of the national primary health care
system.
 Improve the availability, accessibility, affordability and quality of health services
(including human resources and drugs) through decentralisation and devolution of
decision making and budgets in line with Primary Health Care (PHC) for UHC.
 Reinforce institutional capacity to facilitate intersectoral collaboration and stakeholder
engagement and partnership (government ministries and departments, private,
development partners, NGOs and community) for health care delivery. This will help to
promote synergy and leverage capacity to address the social determinants of health. The
private sector presents opportunities to improve access and increase coverage of
services to meet national goals. A private sector policy has been developed to
coordinate and deepen the engagement and requires implementation.
 Strengthen coordination, cohesion and accountability in the health sector. In particular,
enhance transparency, efficiency and accountability in the governance and management
of all resources including public funds, the AIDS Levy, the Health Levy, ratepayers’
contributions, donor funds etc through deliberate training of specific office bearers in
PHC for UHC, participation of civil society in the Ministry of Health, Social Welfare,
Finance their management Committees. This is in line with ensuring the attainment of
the national targets, (NDS1 & 2, NHS 2020-2024) as well as regional and international
best practice.
 Review the health staff establishment to reflect the current environment of increased
population, high disease profile with very high death rates and reduced access to health
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care services. Appropriate incentives must be designed to ensure equitable distribution
across urban and rural areas ensuring access to under‐served populations.
 Intensify prevention and control of non-communicable and communicable diseases,
conditions such as mental, substance abuse, and injuries from high level of road
accidents, nutritional deficiencies and epidemics/pandemics.
 Improve health information management systems including reporting of community
events for rapid action.
 Improve research funding and output in the health sector as well as in the sectors
hosting key determinants of health for generation of evidence and more locally
appropriate actions and achievement of goals and targets.
 Explore options and possibilities for domestic resource mobilization and the
introduction of a national health insurance scheme to ensure universal health coverage.
Currently only about 7% of Zimbabweans have access to medical insurance and this
number is insufficient to ensure decent public healthcare. No country can prosper
without a healthy citizenry. In line with regional and global best practices, the National
Health Insurance can be publicly funded through a combination of sin taxes as well as
sugar taxes to ensure primary health care to every Zimbabwean. The WHO has been
advocating for a sugar tax on sugar-sweetened beverages to fight the scourge of noncommunicable diseases. The sugar tax, apart from reducing consumption of sugary
drinks, also raises additional revenue for the treasury.
 Enhance health service delivery through leveraging digital economy e-Health platforms
such as telemedicine.
 Improve investments in mental health. The mental health effects of the economic crisis
and the COVID-19 pandemic can be counteracted through investments in social welfare
and the implementation of other policy measures such as active labour market policies
to help citizens to enter the labour market or to prevent already employed individuals
from losing their jobs.
 Support adolescents to acquire skills and knowledge for healthy sexual development
and behaviour.
1.0 Introduction
There is a positive correlation between health expenditure and economic growth. Health care
spending stimulates economic growth: as health is a form of capital, investment into health
can increase both human and physical capital accumulation (through enhancing productivity,
incomes, and wellbeing), leading to overall economic growth and development. Healthier
people are wealthier and more productive. Thus, prioritizing health can be a catalyst for a
broader virtuous cycle of growth. Empirical evidence has found that for every $1 invested in
health there is an economic return of between $2 to $4 across developing countries1
.
The Government has committed itself in the 2013 Constitution and National Health
Strategies, (2016-20, 2021 – 24) and the ZIMASSET, NDS 1 & 2, to ensuring healthy lives
and promote well-being for all at all ages. The country therefore has a strong institutional and
policy framework to ensure healthy lives and promote wellbeing for all. Health is recognised
as a fundamental right in the Constitution. Health and well-being is one of the priorities under
the National Development Strategy 1. At the continental level the country has committed

1 https://www.brookings.edu/blog/future-development/2020/07/21/how-investing-in-health-has-a-significanteconomic-payoff-for-developing-economies/
3
itself to the Abuja Declaration of 2001, the Addis Ababa Declaration of 2006 on community
health, the 2008 Ouagadougou Declaration on Primary health care and health systems in
Africa and the 2012 Tunis Declaration on value for money, sustainability and accountability
in the health sector. Sustainable Development Goal 3 of the United Nations (UN) seeks to
ensure healthy lives and promote wellbeing for all at all ages by 2030. However, there is an
urgent need to translate these noble commitments into actions through adequately and
efficiently allocating resources to the health sector if the 2030 goals and targets are to be met.
A key lesson from the COVID-19 pandemic is that the benefits of health investment go
beyond the health sector to the general prosperity and security of the population more
broadly. The COVID-19 pandemic has highlighted the importance of strengthening the public
health security system and ensuring universal health coverage (UHC) and confirmed the need
for greater and more secure public funding for health. However, while health has long been
recognized as a key aspect of development, investment decisions around health have too
often been evaluated purely as a cost, not as an investment with an economic return. This is a
mistake because improving health is necessary for prosperity.
The Community Working Group on Health (CWGH) is a network of community/civic based
organisations whose aim is to collectively enhance community participation in health in the
country. The formulation of the National Budget is an area that requires greater participation
of the community. Community participation in health matters and budget formulation gives
the citizens an opportunity for their voices to be incorporated in the National Budget as
provided for in the Constitution and the Public Finance Management Act. The CWGH
undertook consultations in the 10 provinces of the country where the CWGH is operational
and the sample of respondents included CWGH national network members, CWGH District
Health Forums (Chapters), Health Centre Committee (HCC) members, Community Health
Workers and CWGH Community Volunteers with a balance between men and women. We
also incorporated submissions from the Project Steering Committee and Core Group of the
PHC for UHC, the PHC Policy Brief and from the Pre-Budget consultations of the Parliament
Portfolio Committee. This submission captures the main issues that came from these
stakeholder consultations across the country on the state of health, its social determinants and
on the consensus that revitalization of Primary Health Care is the best way for the country to
revive the fragile health delivery system and unlock the human potential that will spur the
country to achieve its 2030 targets of an “empowered upper middle-income economy”, and
the SDGs. The question on what must be done to address the challenges plaguing the health
care system must therefore be urgently addressed. This position paper is therefore a synthesis
of the views of the citizens towards the National Budget.
2.0 Key Social Determinants of Health
The 1976 charter of the World Health Organization (WHO) has defined health as “a state of
complete physical, mental and social well-being” and not simply as the absence of disease or
infirmity. Thus, the concept of health is not only defined from a medical perspective, but also
as something influenced by other non-medical factors, such as the state of the economic (or
macroeconomic environment); education; water and sanitation; housing; and the physical
environment. For instance, an underperforming economy has a negative impact on health
indicators such as life expectancy, morbidity, mortality, access to health services, and
weakening of the healthcare system. This is all well-articulated in the formative documents
that shaped our health care delivery system at independence, the White paper on Health,
Planning for Equity in Health, the National Health Strategy 1997-2007, the national
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Constitution, 2013, the national development strategies; ZIMASSET, NDS 1 & 2 and the
National Health Strategies, 2016-2020 and 2021-2024. Implementation which has to date
been lacking will now require serious planning and auctioning if the country is to achieve its
2030 goals.
2.1 Macroeconomic Environment: The economy continues to face structural challenges
that include: erratic growth pattern; high levels of informality; a huge competitiveness gap;
poor infrastructure; weak institutions; high levels of public indebtedness; high inequalities;
and high levels of poverty. The COVID-19 pandemic has exacerbated these structural
challenges. The economy is estimated to have grown by 7.8% in 2021, following 2 years of
successive economic decline in 2019 and 2020 (see Table 1). This improvement in 2021 is
largely on account of a good 2020/21 agricultural season and increasing international
commodity prices among others. Zimbabwe’s economic growth for the year 2022 is officially
projected at 4.6%, the 2022 official projection is above the International Monetary Fund
(IMF) projection of 3.5% and the World Bank projection of 3.7%. The agriculture sector is
projected to decline by -5.0% in 2022 from an estimated 33.6% in 2022. The manufacturing
sector is projected to slow down to 3.6% in 2022 from an estimated 5.5% in 2021. Mining is
expected to grow by 9.5% in 2022 from 5.5%. To achieve inclusive and sustainable
development there is need to ensure that this growth is associated with decent job creation
and poverty reduction. The tragedy for Zimbabwe is that even in those years in which we
have registered positive economic growth, the positive economic growth has not resulted in
the creation of jobs and poverty reduction. Economic growth is vital to sustaining health care
financing and realising the right to health care especially as we move towards universal
health coverage and the SDGs. It is not just the quantum/pace of economic growth that is
vital but also the quality/pattern of that growth. Erratic economic growth has contributed to
limited domestic resources being channelled to health.
Table 1: Selected Macroeconomic Indicators
2009 2010 2013 2016 2017 2018 2019 2020 2021
Real GDP (% change) 7.4 16.7 2 0.7 4.7 3.5 -7.4 -8 7.8
Average Inflation (%) 6.2 3 1.6 -1.6 0.9 10.6 255.3 557.2 144
Gross Savings (% of GDP) -10.1 -5.1 -5.5 -1.5 -1 -3.7 6.6 5.9 –
Investment (% of GDP) 9.9 17 9.2 9.8 8.9 5.7 7 7 –
Budget Balance (% of GDP) -2.2 0.2 -1.3 -6.5 -8.3 -4.7 -1.4 0.4 -0.5
Current Account Balance (%
of GDP) -9.7 -12 -13.2 -3.58 -1.66 -8.3 4.4 4.7 –
Public Debt (% of GDP) 157 118 49 69.7 74.1 51 93.2 102.7 69.5
FDI inflows (% of GDP) 1.09 1.38 2.10 1.81 1.59 3.06 1.28 0.89 0.70
Source: International Monetary Fund, World Economic Outlook Database, April 2021; World Development
Indicators, Last Updated Date: 15/09/20221; 2022 National Budget Statement.
The country is facing a currency crisis which has spawned chronic high inflation. Inflation
has been on an upward trend since January 2022. The main drivers of inflation in Zimbabwe
are money supply growth, the black-market premium (exchange rate developments), and
energy and fuel price developments. Annual inflation rate rose from 60.61% in January 2022
to 191.6% in June and 285.0% in August, the highest annual inflation rate in the world
(Sudan’s June annual inflation rate is 148.9%; Lebanon’s July annual inflation rate is 168%;
and Venezuela has a July 2022 annual inflation rate of 137.1%). In Zambia, annual inflation
rate in July 2022 was 9.9%, in South Africa annual inflation rate in July 2022 was 7.8%,
while in Botswana it was 14.3%. The chronic high inflationary environment continues to
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erode real incomes and thrown many citizens including health professionals into absolute
poverty. The proportion of the working poor has increased markedly with average salaries
lagging the poverty datum line (PDL). As at September 2022, the average net salary for a
nurse comprised ZWL$250,000 (US$330-403) and US$175. In South Africa, the average
monthly salary for a nurse is about ZAR29, 000 (US$1,600).
Zimbabwe is in debt distress with total Public Debt estimated at US$13.7 billion as at the end
of September 2021 up by 28% from 10.7 billion as at end of December 2020, according to
the 2022 National Budget Statement. This increase is on account of the assumption of the
blocked funds (historical foreign currency obligations) estimated at US$2.9 billion and other
non-guaranteed facilities. The December 2020 figure represents 72.6% of Gross Domestic
Product (GDP). This is higher than the 70% threshold provided for in the Public Debt
Management Act (Chapter 22:21) and the SADC Regional Indicative Strategic Development
Plan (RISDP) Public Debt-to-GDP Macroeconomic Convergence Target of 60%. The high
public debt represents an impediment to sustainable economic growth and employment
creation in the economy. The huge debt stock has reduced the availability of both local and
external resources for health-related investments. The high public debt has crowded out
public resources from health care.
The cost of servicing the debt continues to crowd out fiscal resources that could have been
invested in critical social services such as health care and education. As a result, Government
spending on critical sectors such as health remains relatively low. According to the Statement
of Public Debt issued on 24 November 2021, during the period January to September 2021,
debt service payments amounting to US$44.217.0 million were made to external creditors. A
Joint World Bank-IMF Debt Sustainability Analysis carried out in February 2020 shows that
Zimbabwe is classified as ‘in debt distress’, with unsustainable PPG external and total debt
and large external arrears. The country’s current debt-carrying capacity is classified as ‘weak’
according to the methodology employed in the revised DSF Framework (2017). As at end of
2021, the country had a Present Value (PV) of PPG external debt-to-GDP ratio of 74.1%; a
PV of PPG external debt-to-exports ratio of 277.1% per cent; a PPG debt service-to-exports
ratio of 10.0%; and a PPG debt service-to-revenue ratio of 11.5%. The high external debt to
export ratio is of great concern because of its negative effects on investment and savings. The
high ratio points to debt servicing problems, because most of the cash required to service the
external debt largely comes from export earnings. The high debt-to-exports ratio also points
to the fact that Zimbabwe’s debt is unsustainable and likely unrepayable.
Table 2: Debt Sustainability Indicators
2018 2019 2020 2021 2022*
PV of PPG external debt-to-GDP ratio – – 69.5 74.1 68.1
PV of PPG external debt-to-exports ratio – – 286.4 277.1 272.2
PPG debt service-to-exports ratio 12.7 10.7 8.5 10.0 11.9
PPG debt service-to-revenue ratio 12.0 20.0 12.6 11.5 11.8
Source: IMF 2022 Article IV Consultation—Press Release; Staff Report; and Statement by the Executive
Director for Zimbabwe. * The 2022 figures are based on projections.
Meanwhile, the challenges to the health service delivery have multiplied and accumulated;
that is, increased burden of communicable diseases due to the poor water, sanitation, hygiene
and socio-economic status as exemplified by outbreaks of common diarrhoea, cholera,
typhoid, pneumonias and skin diseases, reduced immunization coverage resulting in
previously controlled measles resurgence and other vaccine preventable diseases, a huge
6
unaddressed burden of non-communicable diseases and conditions, (mental health, substance
abuse, malnutrition, traffic crashes, eye, ear conditions, disability, elderly health). These
against a background of a growing population, and much dwindled resources now demand a
much bigger investment in health beyond the 15% budgetary allocation to health and the
fulfilment of the WHO per capita spending on health ($37 with NCDs) if universal coverage
of quality health and the other developmental goals are to be achieved.
Zimbabwe continues to face huge labour market challenges related to poor job quality and
high levels of working poverty. This state of affairs is directly related to the high prevalence
of informal and vulnerable employment. The country faces a scarcity of regular wage
employment for all who would like wage jobs and are capable of performing them. Would-be
wage employees cannot afford to remain unemployed and continue to search, so they find it
better to create their own self-employment opportunities in the informal economy. The few
that are formally employed2
contribute only 10% of the nationals who are formally medically
insured (commercial medical aid) which have largely short-changed the subscribers by not
providing comprehensive cover, with paid up members failing to access health care services
even in facilities they run, (PSMAS, CIMAS clinics and hospitals), and having to pay copayments and shortfalls. They have also not provided for referrals for specialized care
including out of the country when indicated for some of their clients resulting in
complications and avoidable deaths. According to the 2019 Labour Force and Child Labour
Survey, the share of informal employment to total employment is estimated at 75.6% in 2019.
Informal employment is characterised by low productivity, low incomes, high poverty, no
social protection, and lack of workers’ representation among others. High levels of
informality implies that the country has abundant resources that are not being fully and
productively utilised. A dwindling taxable formal sector has contributed to limited domestic
resource revenue raising capacity and constrained public sector health financing in the
country.
The unstable macroeconomic situation has negatively affected the key determinants of health
such as levels of household income and economic well-being; access to safe water, sanitation
and other basic needs; access to essential food and nutrition; levels of literacy and education.
2.2 Access to safe water and sanitation: Water and sanitation are essential for good health
outcomes and sustainable development. Inadequate access to water and sanitation
infrastructure is a major source of health challenges and disease outbreaks such as common
diarrhoea, cholera, typhoid, pneumonias, and skin diseases. Poor and inadequate water and
sanitation is a leading cause of poverty, morbidity and mortality in a number of countries.
Providing water and sanitation in schools is key to keeping girls and children in school, and
also protecting them and women from gender-based violence and sexual abuse when they try
to access scarce or distant water, or wait for nightfall to relive themselves. The occurrence of
drought and low rainfall patterns result in reduced availability of safe drinking water.
Children, particularly girls, are then forced to walk long distances to fetch water in some
cases from unprotected sources often affecting their ability to go to school.
Access to adequate, safe water and sanitation remains a major challenge particularly in rural
areas and informal urban settlements. The increase in population in the large urban
settlements coupled with poor equipment maintenance and upgrades to the water and
sewerage works and solid waste management sites has put a lot of pressure on the national

2 According to the 2022 Q1 Labour Force Survey by ZIMSTAT, 88% of total employment is informal.
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water resources. The country has also experienced a rise in informal settlements where water
supply and sanitation services are virtually non-existent and waterborne diseases are
prevalent. Results from the 2019 LFCLS show that 77.1% of households have access to
improved sources of drinking water down from 78.3% in 2017 (see Table 3). These figures
however hide a wide disparity in access to safe drinking water between urban areas and rural
areas and also even within urban areas. For instance, 97.3% of the urban household
population has access to improved sources of drinking water as compared to 67.9% of the
rural household population. Harare has the highest percentage of households with access to
improved water sources at 96.6%, when compared with 64.8% in Matabeleland South.
Meanwhile, 68.8% of households have access to improved not shared sanitation facility as at
2019 up by 1% from the 2017 figure. Chronic water shortages are more pronounced in urban
areas of Zimbabwe, and are being experienced in the context of increasing water
consumption needs by a rapidly rising housing and population which is not matched by a
corresponding increase or expansion of the amenities.
Table 3: Access to improved water and sanitation among households
Indicator 2005/06 2010/11 2014 2015 2017 2019
Proportion of population using safely managed
drinking water services
75.8 76.7 76.1 78 78.3 77.1
Proportion of population using (a) safely
managed sanitation services and (b) a handwashing facility with soap and water
42.0 37.3 62 37 67.8 68.8
Source: 2014 Multiple Indicator Cluster Survey (MICS); 2015 ZDHS; 2017 ICDS; 2019 MICS.
There are no social services, (clinics, community centres, recreational centres, etc) nor
meaningful and productive use of time for socio-economic advancement of the individuals,
families and the communities, resulting in these unregulated urban settlements demoting
rather than promoting health. There is therefore an observed rising trend in idleness of young
able-bodied persons, promiscuity including pimping of young girls (Epworth), substance
abuse, and crime all of which are contrary to the national development and health agenda.
2.3 Education: Education and literacy are among the major determinants of health and
development. It’s fundamental and indispensable to the realisation of good health. It is the
primary vehicle by which economically and socially marginalized adults and children can lift
themselves out of poverty and obtain the means to participate fully in their communities.
Education equips people with knowledge and skills for problem solving, ability to access and
understand information on health, and helps to provide a sense of control over life
circumstances. Education increases opportunities for job and income security and ultimately
household wealth status all of which have direct impact on the health and well-being of
individuals. Low education and literacy levels are linked with poor health, more stress, low
income and lower self-confidence. The country was previously ranked very high for literacy
levels above 80% but there is evidence of this declining in recent years.
The country continues to face a serious challenge with the high levels of school dropouts.
There were 20,400 dropouts at primary school level (including ECD) and 37,081 at the
secondary school level as at 2018. The main reasons for dropping out of primary school are
absconding (45.1%) and financial reasons (32.9%). A total of 231 learners drooped out of
school for marriage reasons and 180 for pregnancy ones, most of them being females. At
secondary level 3 836 learners (female 3,558: males 278) dropped out of school for marriage
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reasons and 2 912 (females 2,861: males 51) for pregnancy ones. Similarly, the main reasons
for dropping out of secondary school are financial reasons (46.6%) and absconding (27.8%).
More males than females dropped out of secondary school because of financial reasons,
absconding, death and expulsion. In times of economic hardships, older boys may be
dropping out of school to supplement household incomes. This is contrary to the general
belief that people have sceptical attitudes towards the benefits of educating girls.
Investing in school infrastructure especially in the rural areas is vital to improving overall
learning outcomes. Enrolments at rural schools are much lower than for the urban due to the
massive rural urban migration, but this trend should shift with good PHC implementation
which should re-establish value in the rural areas and return to the nation’s cultural values,
tradition and the re-placing/appreciating of our values and dignity in contrast with the current
situation befalling the urban poor. It has been demonstrated that good school infrastructure
enhances pedagogy, improves student outcomes, enable schools and learners to realise the
full potential of technology, as well as contributing towards the reduction of drop outs. While
urban schools are better equipped than the rural schools, there is the challenge of
overcrowding in many urban schools with a number of schools having to resort to hot sitting
(operating shifts) to accommodate the many students.
2.4 Food security: A combination of the below average 2021/22 agricultural crop
production and the macroeconomic instability typified by chronic high inflation have
exacerbated food insecurity within the country. According to the WFP Hunger Map LIVE,
the number of estimated people with insufficient food consumption increased from 5.4
million in the first week of July 2022 to 5.6 million during the third week of September 2022.
According to the World Bank Food Security Update of 15 September 2022, Zimbabwe had
the highest nominal annual food price inflation of 353% in August 2022, followed by
Lebanon (240%) and Venezuela (131%). With the deliberate implementation of primary
health care, individuals, families and communities should find value in returning back to the
traditional and cultural food production, preparation and consumption methods that ensured
that each household within a community had food. The seed for locally consumed vegetables,
crops, fruit trees etc had ensured local availability and was shared at special community
convergence events such as nhimbe, jakwara, mukwerera all of which have died down in
favour of unregulated and unproductive urbanization which is characterized by food
insecurity and malnutrition among both children and adults. For universal health coverage to
be realised in Zimbabwe, there is need to identify and adequately address the key
determinants of health for all nationals regardless of their income status and geographical
location. Furthermore, there has to be a return of the school feeding programme in order to
address nutritional deficiencies as well as attract back and keep children in school particularly
in the arid regions of the country.
2.5 High levels of poverty: According to the World Bank Zimbabwe Economic Update of
June 2021, the number of extremely poor Zimbabweans reached 7.9 million – almost 49% of
the population in 2020, up from 42% in 2019. The high levels of poverty have necessitated
the need for greater social protection support, which has made the role of NGOs even more
significant given the limited fiscal space in government. In urging for the revitalization of
PHC for UHC while also at the mid-point of the SDGs reporting, there is need to work on
improving community resilience and self-sustenance to better take up the responsibilities that
come with the rights to health and all its determinants as the country seeks to become an
empowered upper middle-income economy. On account of the high levels of poverty, a lot of
citizens have been unable to bear the healthcare costs resulting poor health outcomes, even of
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otherwise simple, easy to manage diseases and conditions. However, with deliberate
implementation of primary health care, defined as a strategy for organizing health systems so
they effectively promote health. It encompasses “essential health care made universally
available to individuals and families by a means acceptable to them and at a cost that the
society can afford at every level of their development”. It includes actions across different
sectors; (education, environment, agriculture, water and sanitation, social welfare, finance,
culture and tradition) to promote health. To this end, all actors in health and its determinants
must rally around the communities to empower them for health, explore all possible funding
mechanisms to ensure each health institution is well supplied and managed and the
community health needs met. The health centre committees, district, provincial and central
hospital management boards must now be capacitated to rise up and implement PHC for
UHC.
3.0 Health Situational Analysis
The country’s health sector has been facing numerous challenges. Even before the COVID19 pandemic, the health sector was already facing deep structural challenges. The COVID-19
pandemic only exposed and worsened those challenges. The sector has suffered from years of
gross underfunding and investments, with public health spending accounting for a relatively
small proportion of total government spending, with health sector allocation standing at
10.6% in 2022 down from 13.0% in 2021. Employment costs constitute 21% of the total
health budget while recurrent expenditures account for 84.6% of the total health budget. The
Abuja target remains an elusive target for Zimbabwe (see Figure 1). According to the WHO
countries such as Malawi, Rwanda, Madagascar, Togo and Zambia have managed to reach
the Abuja target. As of 2015, Rwanda was spending at least 23% of its budget on health care.
Meanwhile the Abuja target 20 years later now falls far short of what is required to
resuscitate the national health system, as it was looking to ensure that countries addressed the
then big challenges of AIDS, TB, Malaria and Maternal and Child Health to the exclusion of
all other diseases and conditions. Furthermore, on these it was estimated that allocating at
least 15% of the national budget to health would result in at least 60% coverage on these
selected interventions. The current challenge now as we move towards UHC is that of
bridging this financing gap to adequately address all diseases and conditions in order to
realise universal health coverage, that is100% of the population requiring health services
reached with the appropriate quantity and quality service anytime all the time.
The Government also spends a relatively small share of its gross domestic product (GDP) on
health care. Per capita public health spending also remains inadequate with per capita public
health allocation at US$20 in 2022 down from US$45 in 2021 (as shown in Table 4). Lower
levels of per capita health expenditure indicate that health expenditure in the country is
insufficient to guarantee adequate access and quality of healthcare for the communicable,
non-communicable diseases, injuries and other conditions, other services. The per capita
allocation is much lower when you remove the employment cost component. The per capita
health allocation is lower than the SADC average of US$140. Per capita health expenditure is
US$650 in South Africa, US$90 in Zambia and US$200 in Angola. The country must spend
at least $271 per capita in order to achieve universal health coverage by 2030. This will allow
the fulfilment of the unfinished MDG business and quick movement towards the SDGs,
enroute to attaining the much-desired empowered upper middle-income economy. According
to the WHO, global spending on health averages US$1,080 per capita.
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Table 4: Trends in Public Health Expenditure, 2016-2020
2016 2017 2018 2019 2020 2021 2022
Public Health Expenditure (percent
of total Public Expenditure)
8.3 6.9 9.0 7.0 10.1 13.0 10.6
Per capita public health
expenditure
23 18 20 7 14 45 20
Public health expenditure (percent
of GDP)
2.3 1.9 2.7 2.8 1.4 2.5 1.7
Source: Calculations based on Ministry of Finance figures.
9
9.810.2
9.2
10.9
7
8.7
12.211.5
7.6
9.19.79.6
8.5
6.6
8.3
6.9
9
7
10.1
13
10.6
0
2
4
6
8
10
12
14
16
2001 2003 2005 2007 2009 2011 2013 2015 2017 2019 2021
%
Year
Figure 1: Public Health Expenditure (% of Total Government
Expenditure)
Health Expenditure (% of Total Government Expenditure) Abuja Target
The inadequate public financing of health has resulted in an overreliance on out-of-pocket
and external financing which is highly unpredictable and unsustainable. As shown in Table 5,
as at 2019 the main source of health financing are external aid/financing (29.55%), followed
by voluntary health insurance contribution (27.27%), then out-of-pocket spending3
(24.38%),
and lastly government transfers (17.65%). There is an over-reliance on external aid and outof-pocket spending. Out of pocket payments by households have driven many households
deeper into poverty. The high dependency on external financing is inadequate, unreliable,
unpredictable, unsustainable and highly dependent on the political environment, raising
concerns on the sustainability of health financing institutions and the vulnerability of
government’s budget should external funding be withdrawn. In fact, donor funding is limited
to their areas of interest, subject to change, and not to the country or community needs and
therefore falls far short of what is required for PHC for UHC. External funding has also been
dwindling owing to global economic constraints, and of late the war in Ukraine. Erratic
economic growth and a dwindling taxable formal sector contribute to limited domestic
resource revenue raising capacity and constrain public sector health financing in the country.
The policy on free treatments for pregnant women, children under 5s and those aged 65 years
and above has not been backed by resources nor financial jurisprudence, and has resulted in
impoverishing the health system as these constitute the majority and most regular users of the
health services. It has therefore translated into poor service, over-crowding amidst limited
resources, and a frustrated health workforce all levels who are poorly remunerated and yet

3 According to the 2021 Global Expenditure on Health report by the World Health Organisation (WHO), health
spending in low-income countries was financed primarily by out-of-pocket spending (OOPS; 44%) and external
aid (29%), while government spending dominated in high income countries (70%).
11
have to provide free services to all including those that can pay. This is in contrast to yester
years when all those earning below the minimum wage would be screened by the social and
health services and provided with assisted medical treatment orders (AMTOs) for treatment
at Ministry of Health facilities. The MOHCC would subsequently present these for reimbursement at the Ministry of Social Welfare’s Social Dimensions Fund, (SDF) thus
ensuring both quantity and quality of services were maintained. Moreover, the blanket cover
does not look at ability to pay, and this has resulted in those who have the means including
those pre-paid on medical aid accessing the services for free, impoverishing the system. We
therefore call on stronger management and governance of the health delivery system in
engaging the requisite sector ministries notably Finance, Social Welfare in order that all the
WHO building blocks of a stronger health system are addressed for UHC, leaving no-one
behind.
Table 5: Sources of Health Spending
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Government
Transfers 26.28 26.23 28.89 28.38 33.58 20.82 23.31 24.02 32.06 17.63
External Aid 27.48 19.21 15.34 20.13 20.22 24.26 27.91 20.7 25.71 29.55
Out-of-Pocket
Spending 34.43 37.22 34.97 29.76 24.83 25.79 23.31 22.81 19.7 24.38
Voluntary Health
Insurance
Contribution 11.55 16.88 20.19 21.05 20.97 28.92 25.01 21.78 22.03 27.27
Source: https://apps.who.int/nha/database/country_profile/Index/en
2016 2017 2018 2019 2020 2021 2022
External/Donor Expenditure 346 429 420 483 488 496 499
Public/Government
Expenditure 321 260 291 96 206 684 300
321 260 291
96
206
684
300
346 429 420
483
488
496
499
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Figure 2: Health Expenditure
Public/Government Expenditure External/Donor Expenditure
Source: https://apps.who.int/nha/database/country_profile/Index/en
Figure 3 shows the financing needs across different sectors including health. For instance, the
total financing needs for the health sector is about US$900 million, with the government only
financing about US$100 million, while external donors are financing about US$300 million,
with the balance of about US$500 million being unmet financing needs. As we move towards
UHC these financing levels require reconsideration and special considerations made for
additional resources to be availed to health and the determinants of health.
12
Figure 3: Social sector financing needs
As shown in Table 6, the country still falls short of investments in critical sectors of the
economy such as social protection, health, education, water and sanitation. These sectors
underpin the key determinants of health and are critical for enhancing health outcomes and
development. For instance, current public spending on health is too insignificant to ensure a
wealthy and productive nation that is the empowered upper middle-income economy or the
SDGs. The allocations on Health and Basic Education are below the Abuja Declaration
(2001) and the Education for All Initiative (2000) targets/benchmarks of 15% and 20%
respectively, while the social welfare services have been invisible.
Table 6: Sectoral spending targets and performance for Zimbabwe
Sector Agreement Target 2019 2020 2021 JanJune
2022
Revised
2022
Social
protection
Social Policy for Africa
(2008)
4.5% GDP 0.3% 0.7% 0.8% 0.5% 0.9%
Health Abuja Declaration (2001) 15%
government
expenditure
7% 10.1% 13.0% 6.5% 10.6%
Education Education for All Initiative
(2000)
20%
government
expenditure
14.6% 13.3% 13.1% 11.2% 13.4%
Water &
Sanitation
eThekwini Declaration
(2008)
Sharm El-Sheik
Commitment (2008)
1.5% GDP 0.7% 0.7% 0.2% 0.2% 0.5%
Agriculture Maputo Agreement (2003) 10%
government
expenditure
12.7% 17.5% 11.0% 20.2% 13.6%
Infrastructure African Union Declaration
(2009)
9.6% GDP 8% 7.2% 5.5% 1.3% 4.8%
Source: Calculations based on the National Budget statements.
13
An analysis of the 2022 Mid-term Budget shows that out of the original budget to the
Ministry of Health and Child Care of ZWL$117.7 billion, only ZWL$31.8 billion
(representing 27% of the total original budget) had been spent during the first half of the year.
This is a very low utilisation rate and is a worrisome development which brings to the fore
issues of budget credibility, management oversight and overall governance of the health
delivery system. The Ministry of Health and Child Care has lamented the late disbursement
of funds which has been constraining the Ministry’s operations and by the time the funds are
eventually released if they are released at all, they would have been eroded by inflation. For
instance, out of the allocation of ZWL$800 million to Parirenyatwa Central Hospital, nothing
had been disbursed as at 30 September 20224
.
In line with PHC there has to be decentralisation and devolution of the resources, decision
making and services to ensure availability at the point of greatest need, and so that no-one is
left behind. This points to a huge need to improve on the current low levels of health literacy,
financial literacy and health-financial literacy to enable better appreciation of health as a
social, economic and public good, and therefore the vehicle through which the country’s
sustainable development can be guaranteed.
3.1 Composition of Public Health Spending by Programme
The Ministry of Health and Child Care budget has four programmes namely: Policy and
Administration; Public Health; Curative Services; and the Bio-Medical Engineering, BioMedical Science, Pharmaceuticals and Bio-Pharmaceutical Production (BME-BMS-P-BPP).
As shown in Table 7 curative services (Programme 3) was allocated the highest percentage of
the Ministry budget with 66.4%, followed by policy and administration (Programme 1) with
15.9%, while public health got 15.1%.
Table 7: Composition of 2022 Public Health Budget by Programme
Programme
2021 Revised
Estimate
% of 2021 Total
Revised Estimate
2022
Appropriation
% of 2022 Total
Appropriation
Programme 1: Policy and
Administration 10,136,159,990 18.4 18,684,184,000 15.9
Programme 2: Public
Health 5,268,426,980 9.6 17,736,227,000 15.1
Programme 3: Curative
Services 38,492,728,030 69.8 78,123,155,000 66.4
Programme 4: BioMedical Engineering, BioMedical Science,
Pharmaceuticals and BioPharmaceutical Products 1,238,144,000 2.2 3,170,649,000 2.6
TOTAL 55,135,459,000 100 117,714,215,000 100
Source: Proposed Budget Estimates.
Table 8 shows the breakdown of the curative services programme budget. Sub-programme 5:
Rural Health Centre and Community Care got the biggest allocation (30.2%) followed by
Sub-Programme 2: Quaternary Care (Central Hospitals) (29.5%), then District/General

4 https://www.newsday.co.zw/local-news/article/200001130/payout-delays-constrain-health-ministry
14
Hospital Services (26.0%), and Sub-Programme 3: Tertiary Care (Provincial Hospitals) has
the fourth biggest allocation.
Table 8: Breakdown of Curative Services Programme Budget
Sub-Programme
2021 Revised
Estimate
% of 2021 Total
Revised Estimate
2022
Appropriation
% of 2022 Total
Appropriation
Sub-Programme 1:
Quinary (Research
Hospital) 164,672,000 0.4 357,409,000 0.5
Sub-Programme 2:
Quaternary Care (Central
Hospitals) 12,359,328,820 32.1 23,073,926,000 29.5
Sub-Programme 3:
Tertiary Care (Provincial
Hospitals) 4,529,576,300 11.8 10,512,657,000 13.5
Sub-Programme 4:
District/General Hospital
Services 11,966,295,420 31.1 20,336,222,000 26.0
Sub-Programme 5: Rural
Health Centre and
Community Care 9,359,075,490 24.3 23,629,354,000 30.2
Sub-Programme 6:
Traditional Medicines 113,780,000 213,587,000 0.3
TOTAL 38,492,728,030 100 78,123,155,000 100
Source: Proposed Budget Estimates.
Table 9 shows the breakdown of primary health programme budget. Communicable diseases
account for 70.8% of the total appropriation for 2022, followed by family care at 14%. To
achieve the NDS 1 target of reducing non-communicable diseases mortality rate to less than
5% by 2025, there is need to public spending on NCDs.
Table 9: Breakdown of Primary Health Programme Budget
Sub-Programme
2021 Revised
Estimate
% of 2021 Total
Revised Estimate
2022
Appropriation
% of 2022 Total
Appropriation
Sub-Programme 1:
Communicable Diseases 1,782,181,000 33.8 12,549,308,000 70.8
Sub-Programme 2: Family
Health 1,862,128,420 35.3 2,482,058,000 14.0
Sub-Programme 3: NonCommunicable Diseases 145,677,720 2.8 861,064,000 4.9
Sub-Programme 4:
Environmental Health 1,478,439,840 28.1 1,843,797,000 10.4
TOTAL 5,268,426,980 100 17,736,227,000 100
Source: Proposed Budget Estimates.
Zimbabwe suffers from inadequate public infrastructure and ill-equipped hospitals. The
infrastructure which was fashioned during the colonial era and characterized by large
hospitals in the urban areas, rural hospitals, faith-based hospitals and clinics in the rural areas
(tribal trust lands) polyclinics and clinics in the large urban areas, and general hospitals and
15
clinics in the smaller urban areas. In line with the primary health care approach adopted at
independence in 1980, the health system was reformed and health services decentralized,
district hospitals were built and the general hospitals were designated provincial hospitals and
a referral system put in place. According to the national health strategy, 1997-2007 this put
85% of the population within a 10 km radius of a clinic. There have been no efforts to further
characterize or improve the access of the remainder 15%, nor to reassess the access to healthto-health services in the aftermath of the 2000 land reform program. A number of patients
are still enduring having to travel inordinately long distances to access primary health care
facilities. A number of rural clinics face funding and supply water and electricity challenges,
and in Harare there have been 7-9 clinic closures and massive downsizing of the work at the
two infectious diseases hospitals at a time when the city should have been expanding in
accordance with increase in disease burden and the population increase.
The country also faces a critical shortage of healthcare staff with the number, quality and
capability of health care workers as a ratio of the population being critically low. The
depleted health personnel are also highly demotivated owing to dwindling real incomes, poor
working conditions and underequipped and under supplied health institutions. For instance,
according to the World Bank, Zimbabwe had 0.2 physicians (per 1,000 people) as at 2018
when compared with 0.1 in Zambia, 0.8 in South Africa, 0.3 in Botswana, 2.5 in Mauritius,
and 0.6 in Namibia5
. According to the WHO database, as at 2014 Zimbabwe had a skilled
health professionals’ density (per 10,000 population) of 12.44. This points to a huge deficit.
WHO identified in 2006 a minimum density threshold of 22.8 skilled health
professionals/10,000 people to provide the most basic health coverage. Most rural health
facilities have on average 2-3 nurses. This is grossly inadequate as the catchment area of the
clinics is increasing with population increase (13,061 million in 2012 and 15,179 million in
2022), land resettlement and with the influx of gold panners and this negatively affects
service delivery. Consequently, nurses are forced to attend to critical conditions while
ignoring primary health care issues. District hospitals also lack specialised health personnel.
The country continues to experience an exodus of health care professionals. For instance,
between January and March 2022, 379 health practitioners, including 28 medical doctors and
236 nurses, resigned6
. High drop-out rates in public sector health care posts have resulted in
vacancy rates of over 50% for doctors, midwives, laboratory, and environmental health staff.
Emergency medical services in Zimbabwe remain relatively under-developed and underresourced especially in the rural and resettlement areas, but also in the urban areas where
accident and emergency services remain way behind the levels of injuries currently
experienced on the roads. Zimbabwe has among the worst rates of road traffic crashes given
the human, vehicle population and state of roads, yet the corresponding capacity to handle
injuries has not risen to math this high burden. This has resulted in large numbers of
avoidable deaths, complications and disabilities. There is no surveillance nor provision of
emergency services even along the major transport routes where frequent traffic crashes are
repeatedly reported. The institutions located along these routes remain ill equipped to
adequately handle injuries, while referrals to the major cities take too much time to respond
within the golden hour following a crash. The cost of specialist services remains high and
beyond the reach of many. The majority of the country’s districts have just 2 or less
ambulances thereby leaving the burden to the communities to look for unreliable, unsuitable
and unsustainable alternative transport. The situation is worse in most of the resettlement

5 https://data.worldbank.org/indicator/SH.MED.PHYS.ZS
6 https://africanarguments.org/2022/08/zimbabwe-struggles-to-provide-mental-health-support-amid-risingdemand/
16
areas where communities still walk long distances to the nearest health centre. According to
the 2022 National Budget Estimates book, only 25% of the provincial hospitals are providing
selected major surgeries, while there are no provincial hospitals offering selected specialist
services. Only 20% of the hospitals are providing chemistry and haematology analysis
services and only 10% of the health facilities are providing at least 80% of tracer medicines
above minimal levels. There are no Village Health Workers that have been trained in the new
Community Package of Care.
The country is experiencing rising incidence and burden of non-communicable diseases.
Rapid unregulated urbanisation and changes in lifestyle are causing an increase in the risk
factors that cause both communicable, non-communicable diseases (NCDs), traffic crash
injuries, other conditions of public health importance such as prostitution, substance abuse.
For instance, the prevalence of hypertension is estimated at about 30% of the total population,
which is higher than HIV, tuberculosis and diabetes. Addressing the burden of noncommunicable disease constitutes an integral part of achieving SDG 3, “Good Health and
Well-Being”. The target set out in SDG 3 is to reduce premature mortality from noncommunicable diseases, through prevention and treatment, by one-third by 2030.
The cost of NCDs diagnosis and treatment remains very high and unaffordable for most
people. For example, treatment of cancer costs on average between US$100-1000 per
session. In most rural health centres, the only cancer services on offer are screening using
VIAC and referrals for further tests, treatment and therapy at district or provincial level.
Costs related to cancer screening and treatment are not easily accessible due to centralization
to Harare and Bulawayo, and remain beyond the reach of many. Those without the means or
else relatives who can facilitate their stay in the two cities while they get cancer treatment fall
off with complications and death, and the elderly generally tend to ignore symptoms and have
termed prostrate and penile cancers as “old man diseases” that are to be expected and
ultimately result in one`s death. The low recovery rate of cancer patients has also increased
the lack of confidence that communities have in the public health delivery system resulting in
many diagnosed cancer patients seeking alternative treatment options.
The two public cancer treatment centres that offer chemotherapy and radiation treatment at
subsidized prices in Bulawayo and Harare are oversubscribed and again poorly staffed and
equipped such that the quality of service delivery is compromised. The medications needed
for chemo and radiotherapy are also not always available at these two centres and in the
private sector very expensive and many people cannot afford to go for more than one session
and as a result progress quickly in the cancer staging and this results in a high number of
avoidable deaths. The “poor” service delivery that public hospitals are known for has also
resulted in a large exodus to mission hospitals such as Karanda in Mount Darwin, All Souls
in Mutoko and Saint Alberts in Mazowe where people feel services are available, of high
quality and at more affordable prices.
The high costs of cancer treatment, limited services on offer and general limited information
at community level is also contributing to the high number of people seeking cancer
prevention and treatment services from traditional and faith healers. There is need for the
government to invest extensively in cancer research with focus on prevention, treatment, care
including exploring the natural and traditional remedies and support mechanisms for
comprehensive care and support to address this huge emerging health crisis. There is also
need for collaboration between the health ministry and alternative health service providers to
tap into existing knowledge systems and practices that can be adapted to assist in combating
17
cancer. Zimbabwe is rated among the top five most burdened countries for cervical cancer in
the world and once the health care system is back on its feet this statistic can be reversed.
Corruption and misuse of resources remain endemic in the health sector. Corruption diverts
much-needed resources away from health care delivery and reduces patient access to
services. Examples include medical staff who divert drugs and spend more time in private
practice when they are supposed to be working in public hospitals. This has led to insufficient
drugs in most healthcare centres in the country. Reports by the Comptroller and Auditor
General have exposed poor corporate governance practices and financial irregularities owing
to weaknesses in the internal control systems of the Ministry of Health and Child Care and
parastatals under the Ministry. This needs to be corrected in line with the WHO building
blocks for a string health system, Constitution, 2013 provisions in order to achieve national
goals and targets.
Despite challenging economic conditions and dwindling allocations of the national budget to
health, Zimbabwe has made significant progress in the health front owing largely to external
financing from development agencies. These gains relate to significant declines in the HIV
prevalence, child mortality, maternal mortality, scaling up of vaccinations of children and
increase in life expectancy. Notwithstanding these milestones there is a need to close gaps in
coverage and outcomes by eliminating huge income and urban/rural differentials in key
health indicators. The revitalization of PHC for UHC is envisaged to assist in closing these
gaps and making all Zimbabweans players and contributors to their health and well-being
enroute to achieving upper middle income economy status.
The COVID-19 pandemic has exerted a lot of pressure on the health sector and exacerbated
the health crisis. Before COVID-19 pandemic the country in partnership with development
partners had managed to score some notable achievements with respect to key health
indicators. These achievements include: the significant reductions in mortality ratios. As
shown in Table 10, the maternal mortality ratio (MMR) declined from 651 per 100,000 live
births in 2015 to 462 in 2019 and 363 in 2022. The MMR was higher in rural areas (402
deaths per 100 000 live births) than in urban areas (298 per 100 000 live births). While this
decline is positive and commendable, the ratio still remains unsustainably high. The high
ratio is attributable to a number of factors that include: failure to access ante-natal services, a
type of preventive health care whereby regular check-ups are provided to prevent potential
complications throughout the course of pregnancy; delays in reaching health care facilities
owing to poor public transport system in some areas; inadequate public health care financing;
human resource challenges; and refusal to use modern medicine in some communities owing
to religious and traditional attitudes. Zimbabwe has a long way to go to meet the UN SDG
target of 70 deaths per 100,000 live births by 2030.
The infant mortality decreased from 50 per 1,000 live births in 2011 to 47 in 2019 and 24.2 in
2022. The under-5 mortality rate on the other hand decreased from 84 per 1,000 live births in
2011 to 65 in 2019 and 39.8 by 2022. In terms of the share of women with a live birth in the
last 2 years whose most recent live birth was attended by skilled health personnel, there was
an improvement from 80% in 2014 to 86% in 2019. Skilled birth attendance during delivery
is vital in the reduction of maternal deaths.
18
Table 10: Mortality Rates
2011 2014 2015 2017 2019 2022*
Maternal Mortality Ratio 960 614 651 525 462 363
Under-5 Mortality Rate 84 75 69 72 65 39.8
Infant Mortality Rate 57 55 50 52 47 24.2
Neonatal Mortality Rate 31 29 29 – 32 9.5
Source: 2019 MICS, 2017 ICDS, 2015 ZHDS, 2014 MICS, 2010-11 ZHDS.
*The 2022 statistics are from the 2022 Population and Housing Census Preliminary Report on Mortality and
Orphan hood.
The macroeconomic challenges have taken a severe toll on the mental health of citizens. The
COVID-19 pandemic exacerbated this. The mental health care system in the country is
underfunded and understaffed. While the number of patients with mental health issues has
ballooned, the number of psychiatrists has not increased in line with the increasing number of
patients. It is estimated that in 2020, there were 18 psychiatrists — 94% of whom worked in
Harare — and 917 psychiatric nurses. Parirenyatwa Annexe Psychiatric Unit, which can
admit up to 80 patients, relies entirely on recurrent grants from the treasury because it does
not have direct budget allocation7
. The country has been experiencing an increase in cases of
drug and substance abuse, resulting in an increase in the admissions at mental health
institutions. For instance, about 60% of male patients admitted at Ingutsheni Central Hospital
are as a result of drug and substance abuse by youths8
. There is also poor rehabilitation
services for abuse of alcohol and other substances
According to the 2019 Multiple Indicator Cluster Survey (MICS), the country has a high
adolescent fertility rate of 108 births per 1,000 among young women aged 15 to 19 years. The
adolescent fertility rate is much higher in rural areas at 136 when compared with 62 in urban
areas. The high local fertility rate compares unfavourably with average fertility rate of 101
births per 1,000 young women aged between 15 and 19 in sub-Saharan Africa9
. Poverty is a
major driver of the high level of fertility among adolescents in the country. Pregnancy during
adolescence increases the risk of morbidity, HIV infections and mortality for both mother and
child. This could also lead to adverse social consequences such as limitations in educational
and employment opportunities.
4.0 Conclusion
The country has been facing structural social and economic challenges, rising incidence of
poverty, food insecurity, rising informality, increasing unemployment and underemployment
negatively affecting health outcomes. In particular, dealing with the following key
determinants of health will significantly improve the performance of the health sector:
rehabilitating and expanding key infrastructural facilities; improving access to potable clean
water and sanitation; ensuring environmental sustainability in the use of natural resources;
improving transparency and accountability in the use of public funds and other national
resources. These factors and key determinants have to be addressed holistically and
comprehensively with a deliberate implementation of a revitalized PHC in order to improve

7 https://africanarguments.org/2022/08/zimbabwe-struggles-to-provide-mental-health-support-amid-risingdemand/
8 https://newziana.co.zw/2022/09/30/drug-abuse-related-admissions-strain-mentalhospitals/?utm_source=rss&utm_medium=rss&utm_campaign=drug-abuse-related-admissions-strain-mentalhospitals
9 https://www.voanews.com/a/covid-19-pandemic_zimbabwe-reports-major-rise-teen-pregnancies-duringpandemic/6204648.html
19
the conditions of health and development. It is particularly important to broaden the tax base
by dealing with the problem of informality and to explore all possible avenues of domestic
resources mobilization to close the persistent health financing gap to enable the country to
achieve UHC and therefore the national development goals and the SDGs. The overall level
of economic development is a key factor in determining the options for expanding health care
coverage. The country must reaffirm and demonstrate its commitment to the values and
principles of primary health care namely: equity, solidarity, social justice, universal access
and community participation.
5.0 Key Recommendations
5.1 Ensure sustainable financing for health care delivery and financial protection for
the poor by implementing the comprehensive national health financing strategy.
Increasing health expenditure in tandem with the increased population, disease burden and
new national development goals remains a challenge to the health sector. Similarly, the sector
is confronted with ensuring that the poor and the vulnerable are also able to afford quality
health services. The COVID-19 pandemic has highlighted the importance of strengthening
the public health system and ensuring universal health coverage (UHC). No country can
make significant progress towards universal health coverage (UHC) without relying on
dominant share of public funds. Public funds and therefore strategic domestic resource
mobilization for health and its determinants are essential for UHC and for achieving the
national goal of an empowered upper middle-income economy by 2030. These include the
road levy, diaspora remittances, private and individual philanthropists, natural resource
governance beyond the community share ownership trusts, while reviewing the AIDS levy,
Health levy for improved effectiveness and efficiency of deployment. The current health
financing model remains unsustainable as it heavily relies on external financing as well as
Out of Pocket (OOP) financing. In line with regional and global best practices, Government
should urgently explore a number of options and strategies for innovative mobilisation of
resources. The WHO has been advocating for sin taxes including a sugar tax on sugarsweetened beverages to fight the scourge of non-communicable diseases. The sugar tax, apart
from reducing consumption of sugary drinks, also raises additional revenue for the treasury.
5.2 Establish a National Health Insurance Fund that is publicly funded through a
combination of individual contributions from the formal and informal sectors, and establish a
firm pre-payment system for health care provision at all levels of care, sin taxes as well as
sugar taxes to ensure primary health care to every Zimbabwean. The WHO has been
advocating for a sugar tax on sugar-sweetened beverages to fight the scourge of noncommunicable diseases. The sugar tax, apart from reducing consumption of sugary drinks,
also raises additional revenue for the treasury. Currently only about 7% of Zimbabweans
have access to medical insurance and this number is insufficient to ensure decent public
healthcare. No country can prosper without a healthy citizenry, and certainly no empowered
upper middle economy can be achieved let alone the SDGs given the unfinished MDGs
agenda and the current population health status.
5.3 Enhance public financial management and accountability systems in the health
sector. As a move towards health financing, Zimbabwe is currently implementing the Health
Levy Fund, where 5 cents for every dollar of airtime and mobile data goes to health, under
the theme, ‘Talk-Surf and Save a Life.’ The Ministry of Health and Child Care is ringfencing the financial resources mobilised through this levy for the purchase of drugs and
equipment for public hospitals and clinics. There is however a need for greater accountability
20
and transparency in the management of the Health Levy Fund to ensure that funds are being
spent as they were promised. Furthermore, all levels of health care, that is clinic, district,
provincial and central hospital must have timely and adequate disbursements to improve
efficiency of operations, maintain staff motivation and patient satisfaction with the services.
The road levy must also now be accessed for the introduction and full capacitation of
emergency medical services and injury management in the areas most hit by road traffic
crushes, including along the busy highways and transport routes.
5.3 Strengthen public health infrastructure including referral, district and community
centres. Public health infrastructure has been referred to as ‘the nerve centre of the public
health system.’ These are building blocks that underpin public health activities and practices
and include: physical infrastructure; a capable and competent workforce; up-to-date data and
information systems; and institutions with the capacity to address and respond to public
health needs. Public health infrastructure provides the necessary foundation for undertaking
the basic responsibilities of public health and of a strong resilient health system akin to that of
Zimbabwe in the mid-80’s to late 1990s. Government must allocate funds towards improving
basic health infrastructure in the urban, resettlement, mining and rural areas. The public
health infrastructure is old and mostly inherited from the colonial period when the population
then was less than 2 million. Apart from the family health projects which provided district
hospital infrastructure and some equipment, there has not been significant infrastructural
upgrades, expansions nor new works, despite significant population and disease burden
increases, (population Censuses, 1982, 92, 2002, 2012, 2022 and Demographic and Health
Surveys 1985, 90, 95, 00, 05/6, 10, 15, 2020; HMIS, National Cancer Registries).
Contrary to provisions of the Public Health, the large cities are neither preventing nor
managing infectious and other diseases. Harare and Bulawayo have downgraded services at
their infectious diseases hospitals, (Wilkins, Beatrice Road and Thornigrove infectious
Diseases Hospitals) when they should have upgraded these facilities, built new ones as their
urban populace and disease burden increased. Gweru and Mutare have non-functional
infectious diseases hospitals, no laboratory facilities while Masvingo, Kadoma, Marondera,
Kwekwe and Chitungwiza have none. Given their large and underserved (water, sanitation,
waste management, electricity) populations which give way to preventable diseases and
conditions, this situation is not tenable and certainly not in favour of the country achieving
any health and development goals.
Priority must be on strengthening the referral, district and community health centres to
promote preventive health care as well as the curative and rehabilitative interventions, given
the current population health status which is characterized by high morbidity and mortality,
(DHS, MHIS, and Census 2022). A significantly larger share of the budget should go to the
district level, however the current situation demands resources to be urgently availed at all
levels in order to restore normal services. For example, the central hospitals in both Harare
and Bulawayo have downgraded their services to below district level capacity, which
scheduled and some emergency surgeries and outpatient consultations being repeatedly
cancelled, and patients being requested to provide all medicines and sundries for their care,
those who can’t being turned away. City of Harare closed 9 clinics and those left open restrict
the number of patients seen daily and turn the rest away regardless of disease or condition.
Currently there is a bias towards curative interventions and this is not sustainable and must be
corrected through greater investments in preventive care. Government must increase funding
for urban and rural councils and missions in order to strengthen primary level of health care
and reduce unnecessary referrals to higher levels. Funding for mobile outreach services is
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required so that communities in remote areas and newly resettled and the expanding urban
and peri-urban areas can access primary health care and referrals. A significant share of the
national Budget should be allocated to the district level health system as the core or hub of
health service provision, bridging the community health facility level and the referral levels
of the system. Investing in district and community health systems should be a priority that
can contribute towards universal health coverage and the achievement of the SDGs.
5.5 Promote partnerships with the private sector. Capacity of the private sector, including
NGOs is not fully being mobilised for lack of clear guidelines and rules of engagement. As
the country moves towards UHC and economic empowerment for development, it is
important that the private sector be more involved in both supply of health services (including
development hospital, clinics, diagnostic centres, education institutions, etc.) and demand for
health services. The participation of the private sector in the health sector will help to bridge
the huge resource deficit and provide state-of-the-art equipment at public health institutions,
while also ensuring their improved involvement in the national health delivery system
including reporting statistics on their individual and joint activities. There is however need
for a strong regulatory and governance framework governing PPPS in the health sector.
5.6 Address the human resources situation. The Ministry of Health and Child Care used to
be the favoured employer ahead of the city health departments, the WHO and others. Health
care workers would leave employment from these and favour working for government, so the
current outward migration is the opposite of the situation in the 1990s. This is the time to
ensure that Ministry is the employer of first choice for all health workers, if the national
health strategy, national development goals and UHC are to be achieved. Review the staff
establishment to reflect the current environment. There is a need for the absorption of all
required health personnel, including the produced graduates by removing the moratorium on
public health posts. As part of the process of expanding coverage to a larger proportion, it is
imperative that Human Resources for Health (HRH) planning takes into account
epidemiologic, demographic trends and developments. The revitalization of PHC for UHC
will demands additional and well-trained staff to ensure the health system transformation as
well as monitoring progress towards the country’s desired 2030 goals. Appropriate incentives
must be designed to ensure equitable distribution across urban and rural areas ensuring access
to under‐served populations.
5.7 Address the essential drugs shortages. To address the drugs shortages there is need to
revisit and strengthen the essential medicines approach, explore better procurement and
supply mechanisms to all levels in order to address local needs as well as build the capacity
of local drugs manufacturers such as the National Pharmaceutical Company and CAPS.
Pharmaceutical institutions must also be prioritised in terms of foreign currency allocation.
Government should also reduce the high disease burden by prioritising public health
interventions to clear backlogs in identified diseases and conditions, address the key
determinants of health in sector ministries and in the population, and promoting primary and
essential healthcare.
5.8 Improve health information management systems including research in the health
sector. The health information system has continually performed well as it is founded on the
primary health care principles which gave the country its previous health leadership
prominence. In 1987 the system was awarded a SADC trophy for the best surveillance
system. With the advent of technological advancements in HMIS, the system has been
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updated to migrate to the DHIS platform and now e-health and the electronic health record
and telehealth. The latter need to urgently develop to provide the guidance, monitoring and
evaluation not only now at the mid-point of SDGs reporting, but all the way to UHC, upper
middle-income economy and the SDGs.
The Ministry of Health should improve its data analysis, processing and use, given that the
country has sound and credible data sources. These include the population censuses
conducted every 10 years since Independence, Demographic and Health Surveys also
conducted every 5 years since Independence, the Multiple Indicator Cluster Surveys, other
surveys, the central registry and vital statistics. This national data framework should therefore
adequately inform where the country is at as regards the unfinished MDGs business and
therefore inform on a regular basis the progress towards the health, social, economic
development goals desired for 2030 and the SDGs.
Current research activity within the health sector is very minimal and often driven by outside
interests as funding for health research is inadequate to incentivise innovation. With
revitalization of primary health care and the move towards economic development and an
empowered middle-income economy a local health/health determinants research agenda will
be required to adequately inform the country and communities of progress or lack and
therefore corrective actions before 2030.
5.9 Enhance health service delivery through leveraging digital economy platforms such
as telemedicine. The country has benefited from the Ministry of #ICT, Postal and Courier
Services and the national e-governance framework. A number of programmes within the
Ministry have embraced e-platforms for patient tracking, follow up and for health events
reporting with some of the data getting reported in the DHIS. Working with the International
Telecommunications Union, the World Health Organization and the Ministry of ICT progress
has been made to usher in a deliberate e-Health Strategy to enable more efficiency and interoperability. As the country makes bold steps towards the 2030 goals of socio-economic
transformation, economic empowerment and development the digital platforms become
critical to ensure universal and comprehensive health care and reporting and to ensure no-one
is left behind. The e-Literacy must therefore be a priority in order to address the current echaos that has resulted in inefficient and sometimes non-use of some costly digital resources.
Specific workforce will require to be trained for the various aspects of e-Health, while the inservice workforce must receive training and orientation on e-Health. Again, this calls for
inter-sectoral collaboration between Ministries of Health and ICT and partnerships.
5.10 Improve investments in mental health. The mental health effects of the economic
crisis and the COVID-19 pandemic can be counteracted through investments in social welfare
and the implementation of other policy measures such as active labour market policies to help
citizens to enter the labour market or to prevent already employed individuals from losing
their jobs.
5.11 Support adolescents to acquire skills and knowledge for healthy sexual
development and behaviour. Strengthening sex education is a primary strategy for
achieving improved adolescent sexual health outcomes through improving sexual health
literacy, building awareness, confidence and skills.
It is the CWGH’s humble request that these community submissions be taken into
consideration when the 2020 National Budget is being formulated.