Give health sector adequate funding

Robust outreach programmes enable those in areas without established health services to access care and treatment
Itai Rusike Review Correspondent
As government undertakes the 2016 budget formulation process, priority should be given to adequate funding of the health sector to ensure universal health coverage as the cost remains beyond the reach of many Zimbabweans.
The Government needs to honour the Abuja Commitment and allocated 15 percent of the national budget to health instead of the less than 10 percent allocated in 2015.
Six countries; Liberia, Madagascar, Malawi, Rwanda, Togo and Zambia have achieved the Abuja Target proving that we can do it too. Of note is Rwanda which spends at least 23,7 percent of its budget on healthcare.
Rwanda and Malawi have done remarkably well in improving their overall health outcomes and status. Other countries such as Mali and Ethiopia, who are moving towards realising the Abuja commitment, are also doing well in reducing maternal mortality.
The principle that health is a basic and fundamental human right can never be overemphasised, particularly now that the Constitution has clearly stipulated that health care is a right of every Zimbabwean. For any country to be successful it must guarantee that every individual in that country has access to health, which is affordable, available and of high quality.
In the 1980s and 90s, Zimbabwe had one of the best primary health care service models in sub-Saharan Africa but over the years these gains have been eroded by a host of factors including central government’s inability to adequately fund the health sector. Since 1990, life expectancy has been reduced from 63,1 years to 54,1 years for males and 67,7 years to 57,9 years for females.
During the same 80s and 90s era the Government funded up to 90 percent of the country’s health care needs. However, for the past 15 years, households have borne the burden of paying for health care through out-of-pocket (OOPs), while the external partners have increasingly contributed to the bulk of public financing for health services in Zimbabwe.
In the past three years, fiscal allocations to the health sector have been decreasing, impacting negatively on the provision of health care with Government citing tight budgetary constraints.
The inadequate funding for health care has meant that the country has been unable to realise its full potential of providing sufficient and quality services to its people. Many people are succumbing to preventable and treatable diseases such as tuberculosis, malaria, HIV and Aids, cholera and typhoid.
Communicable diseases still remain a cause for concern accounting for over 62 percent of overall mortality in the country. There is need for the Government to devise a funding mechanism for the NCDs, which are costly to diagnose and manage.
Proposals by the Public Health Advisory Board to introduce earmarked sin taxes to fund NCDS need to be followed through. Currently only 9 percent of the health workers have been trained in managing injuries, trauma and other priority NCDs. For diabetes management only 53 percent of the health workers are trained to manage diabetes; all this against a high burden of the NCDs may only a high level of complications and premature or avoidable deaths.
The current National Health Accounts show that patients, through OOPs account for 39 percent of the total health expenditures, followed by the private sector expenditures with 24 percent, external partners with 19 percent and Government with 18 percent.
Presently, external partners through the Global Fund, the Health Transition Fund, The US President’s Emergency Plan for AIDS Relief and Global Alliance for Vaccination and Immunization continue to provide the bulk of the public health financing.
About 98 percent of the drugs in the public health system are funded by external partners. These include anti-retroviral treatment medications (ART drugs), TB and anti-malarial drugs and primary kits for Maternal Neonatal and Child Health (MNCH) services. Most rural and urban area primary services are provided by local government and church related institutions, but inadequate grant support has negatively affected the provision of these services.
The donor dependence syndrome is counter-productive and we urge Government to contribute the majority of the financial resources used in the public health system. The Government needs to therefore increase its domestic funding as this financing mechanism has always proven to be sustainable.
The resettlement of people as a result of the land reform placed people in remote areas or areas which did not have health facilities and adequate sanitation, pushing them beyond the benchmark of the 10km radius from a clinic. Communities in these new areas have either use a lot of out-of-pocket money to travel to access care or in a worst case scenario decide to forgo seeking any health care services at all.
The Government needs to increase funding for outreach services so that communities in these areas can also have access to care. To encourage nurses to do these outreach services, the Government must also consider improving conditions of service and providing incentives to them to work in remote areas.
Blood products have become expensive and inaccessible to many. A bottleneck analysis by the Ministry of Health and Child Care (MoHCC) shows that 60 percent of the secondary facilities had no blood in their stocks. Some of the facilities could not stock blood because there were no refrigerators, electricity and general poor infrastructure. There is need for the Government to consider other alternatives such as solar refrigerators for storing blood products.
Ambulance fees are unaffordable and in some instances, if there is no assurance that someone will pay for that ambulance, the ambulance will not be dispatched leading to complications and death. Further, the state of most of the public facility ambulances is of concern as there are inadequate basic equipment including oxygen and infusion during patient transit and adequately trained staff, again leading to complications and avoidable deaths.
A costed new staff establishment needs to be developed by the Ministry of Health and Child Care’s as the existing staff establishment is not adequate to address the increasing disease burden, population and emerging health threats. This is well articulated in the WHO’s building blocks for health systems strengthening. The Government needs to revise the MoHCC 1980 health worker establishment levels in order to reflect the current workload this needs urgent review to alleviate the staff shortages and consider employment of qualified health workers that are sitting at home due to the current freeze on employment.
In essence the growth in population and disease burden necessitates an increase in both numbers and capacitation of health care workers for the provision of sufficient and quality health care services.
The Government is unable to fill in the current establishment. In some rural health facilities when the only nurse available goes for a workshop, the clinic is closed. Twenty three percent of all provincial and central hospitals do not have dentists. Most district hospitals do not have the four doctors as required in the current establishment. Some district hospitals are manned by pharmacy technicians instead of degreed pharmacists.
The primary care level needs to be funded fully in order to also address non-referrals at the secondary and tertiary levels. There should be district hospitals in Harare and Bulawayo in order to alleviate the burden of patients at the central level. Health Grants to urban local authorities for supporting primary health care delivery need to be provided on time and also increased. This will enable the local authorities to lower their user fee charges to more affordable levels.
While there are existing Government policies to cushion the vulnerable groups from making catastrophic health payments, senior citizens who are exempted from paying user fees are still paying for other access fees such as ambulance services, blood and medications.
We continue to witness the collapse of some medical aid schemes through the mismanagement of funds whilst leaving their members vulnerable. We therefore supports the MoHCC’s efforts of coming up with a Bill for the creation of an independent body to regulate the work of the MAS.
The creation of a National Health Insurance, a process which could have been implemented a decade ago, remains somewhat a non-priority. By urgently addressing this matter Government will reduce the current high levels of catastrophic health spending. The level of consultations that have been done in coming up with the National Health Insurance Bill are not sufficient. In conclusion, community participation matters and health financing, including the budget formulation process give a greater depth to discussion and understanding of the health issues in the country and facilitate appreciation and therefore achievement of the country’s overall health goals.
Itai Rusike is the executive director of Community Working Group on Health, a network of community/civic based organisations whose aim is to collectively enhance community participation on health in Zimbabwe.