Community Working Group on Health

Pregnant mothers, children under five, and adults over 65 years are now exempt from medical fees

The year 2018 began with Government implementing remedial health policy as part of the 100-day economic stimulus plan to make health services accessible to all. Included in the plan is the scrapping of medical fees for infants, senior citizens, pregnant and nursing mothers and slashing the price of blood to $50 at State-run institutions.

The reprieve has been made possible by a more generous budgetary allocation from Treasury, which has brought relief to many in these times of economic hardships. Many have applauded and welcomed this move saying it will make health services accessible to vulnerable populations in line with global commitments on universal health coverage.

This remedial policy, though plausible, has been there since 1980 but had not been fully implemented due to shortages of funding. Executive director of Community Working Group on Health, Mr Itai Rusike, indicated that the recent user fee removal was an advancement of a policy formulated in 1980. The policy was encumbered by a number of weaknesses which Government must address with speed.

“In 1980 a policy of free health care for those on low incomes (below $150, $220)was introduced, and user fees were reduced as a financing source,” he said. “It seems the plan will now be put into action. The policy position on user fees has always been that those who can afford to pay for services should do so but those who cannot should be exempted,” he said.

“He noted that the policy was crippled by the prevailing unemployment rates. The swelling numbers have made the discretionary process of separating deserving persons difficult. Managing exemption from fees has been difficult and costly, with some consequent injustices in who was exempted,” said Rusike.

“In 1990, more emphasis was placed on fee collection although after evidence of high dropout from services, user fees in rural primary health care services were suspended in 1995. The Medical Service Act (1998) gave the Minister the authority to fix fee at Government and State aided hospitals,” said Mr Rusike. He said despite it being a helpful measure from the government, the policy of user fees was viewed as a hindrance to the nation because those who could afford better health standards ended up settling for the free services.

“The National Health Strategy for Zimbabwe 1997-2007 was aimed at free treatment for the majority but also stated that the policy of free health creates a disincentive for people to join medical insurance schemes.”

He added; “Poor people thus faced a variety of de facto barriers: the falling real value of threshold for free care, transport costs, private purchase of medicines due to drug stock-outs and poorly functioning exemption schemes. At the same time higher income earners obtained a number of tax funded public subsidies, including tax relief for medical insurance subscriptions and free services due to difficulties with determining earnings and a treat-first, pay later practice, he enlightened. Even though the policy adjusted in most urban centres, it has never changed in the rural areas.”

“Pregnant mothers, children under five, and adults over 65 years are exempt from fees up to district level but this has been mainly funded by development partners through the RBF funded by the World Bank and the Health Development Fund (HDF), a basket funded by multiple donors that pooled resources in an effort to achieve the complete removal of user fees for the above vulnerable groups.”

He said lack of funding hindered policy implementation, which if not sufficiently addressed can still affect today’s 100-day economic plan. The question has been how the implementation will differ with the old times? There have been concerns about how the government is going to fund the health institutions since the majority of the people are to get the free service? Are health standards going to remain the same under the reduced payments?

Government has assured the nation that there will be no hitches in services, instead sights are on improvements. Minister of Health and Child Care Dr David Parirenyatwa said resources were being mobilised to smoothen the implementation of the idea.

“We want to make sure that all health services are not only available, but also accessible to everyone. We have availed a subsidy of $4,2 million to the NBSZ (National Blood Service Zimbabwe) for them to meet some of the costs associated with blood collection and processing.” There is a budgetary allocation useful for this goal.

“Government is collecting at least $4 million every month from the cellphone levy, the majority of which is used to procure medicines. A five percent allowance is deducted from every $1 worth of airtime bought and is then channelled towards the Health Levy,” said Dr Parirenyatwa.

“Despite the anxiety around the new implementation matrix, hospitals have positively complied with the implementation for many patients have confirmed to the reality of this episode.

“We really appreciate the government’s efforts in making the health services accessible because many were failing to meet the hospital bills leading to a number of people dying,” said Charity Kanhanda, a patient at Parirenyatwa hospital.

“As women we acknowledge the love and appreciation the government has given us as mothers of the country since we are getting everything at maternity for free.” Many also applauded the government’s reduction of blood prices.

“We now have a good government with people at heart. We are so thankful that the government is fulfilling all its promises because I actually bought blood at $50, which is a better price than before,” said Brian Chimboza of Warren Park.

Stimulated by the nation’s response to the implementation, the Permanent Secretary for Health and Child Care, Dr Gerald Gwinji, commended the government’s effort considering the challenges it has been facing towards the implementation. He added; “The main challenge for implementation has been availing commodities and equipment in the face of low budgetary support. Some mechanism must pay for this service when it is eventually availed as free service to the categories of clients.”

“Fears on the implementation of the idea may not be around for long. We have over the years strategised and built support around care for children under five and pregnant women both from government and partners,” said Dr Gwinji. Key challenges which have been plaguing the idea are in the process of being ironed out.

“The main issues were around commodities and this has been largely addressed through various funding mechanisms. The Health Levy, dedicated to commodities like medicines and medical sundries has come in to further strengthening this position,” he said. Dr Gwinji comented on the government’s health budgets that had distressed some citizens considering the economic challenges the nation is facing.

“We have also had slightly better budgets this time around. Putting all this together we feel we have gone over the threshold where we really can support other clients with Assisted Medical Treatment Orders support.

“Going forward, the health financing policy, if fully supported, will create further opportunities for sustainable health care financing from diverse sources of revenue,” assured Dr Gwinji. Health care was one of the most discussed issues within the previous administration.

Concerns with access were raised on numerous occasions. This intervention is likely to bring reprieve to citizens who have been struggling to access health services because of financial constraints.

In extreme cases, hospitals detained new mothers until they had settled their maternity bills. Situations of that nature may be on their way out if the new policy is fully implemented for the benefit of pregnant women, children under five and senior citizens.

Paidamoyo Chipunza and Sheillah Mapani Features Writers

Paidamoyo Chipunza Senior Health Reporter
Harare City Council faces a possible class lawsuit by residents who fear their health has been compromised by being forced to consume visibly contaminated water supplied to their homes by the local authority.

The residents, through the Harare Residents Trust (HRT), a non-profit organisation, have called for the immediate resignation of city officials in charge of water and councillors who exercise oversight over the portfolio for failure to protect their interests.

In an interview with The Herald yesterday, HRT director Mr Precious Shumba said local authorities had a legislative and constitutional duty to provide potable water to residents. He said failure by councillors to ensure residents got adequate supplies of clean water was unpardonable, calling for their immediate resignation.
“Their failure to ensure that residents get sufficient potable water means that they have failed to deliver and hence must not entertain hopes of being retained in their positions. They do not deserve to represent the ratepayers, because they lack an appreciation of what really satisfies the electorate,” said Mr Shumba.

HRT, he said, had prepared submissions that it will take to the Parliamentary Portfolio Committee on Local Government, Public Works and National Housing, including ministries responsible for public health, water and sanitation, to express ratepayers’ displeasure with council’s performance. Mr Shumba urged residents to collect samples of tap water for testing as part of evidence-gathering to be used to sue Harare City Council.

“We are urging residents to take samples of their municipal tap water for tests with the Standards Association of Zimbabwe (SAZ)so that there is evidence of the water status, which we shall be using to sue the City of Harare if it is established that their water has negative implications on people’s health,” said Mr Shumba.

It is however, believed that prosecuting HCC without amending the relevant law will be difficult. Community Working Group on Health (CWGH) executive director Mr Itai Rusike urged the Ministry of Health and Child Care to finalise revision of the Public Health Act, which he said had loopholes that make it difficult to prosecute local authorities for giving residents dirty water.

CWGH is a community-based organisation formed in early 1998 to lobby on health issues. Through the envisaged amended Act, the Ministry of Health and Child Care wants to make it an offence to fail to provide clean water and sanitation to the public.

“There are a number of problems in the environments of health in the capital city, Harare. Unreliable water supplies, prolonged water cuts, uncollected garbage — all lead to unsafe alternatives, which are detrimental to health,” said Mr Rusike.

He said increased cases of diarrhoeal diseases in the capital relative to other cities were clear evidence that the general uncleanliness of the water and the environment in Harare were taking a toll on residents’ health.

“Clean water supplies and environment conditions underlie many of the health problems in Harare and they should be dealt with with the seriousness they deserve.”

Recently, HCC Mayor Councillor Manyenyeni attributed the inadequate water supplies to a shortage of treatment chemicals such as aluminium sulphate, sulphuric acid, HTH Chlorine and activated carbon. He noted that foreign currency shortages are making it difficult to import the critical chemicals.

Statistics from the Ministry of Health and Child Care, Harare tops other cities and towns on diarrhoeal diseases in the country, and this is attributed to inadequate water supplies and poor sanitation facilities. Last year, the city struggled to contain a typhoid outbreak that emanated from Mbare and later spread to other high-density suburbs.

Paidamoyo Chipunza Senior Health Reporter January 6, 2018

Government will use the Health Levy, which has so far received $22 million, to supply vital medicines and medical sundries required by health institutions to implement the free user-fee policy for vulnerable groups, Health and Child Care Secretary Dr Gerald Gwinji has said.

The Health Levy is money realised from a 10 percent cellphone levy deducted from every $1 worth of airtime which was introduced by Treasury last year, half of which is channelled towards health.

Responding to questions on Government’s source of funding for a successful free user-fee policy, which has been in existence since 1980 but was not being implemented due to inadequate funding by Government for health institutions, Dr Gwinji said medicines and medical sundries consume the bulk of institutions’ budgets.

He said a mechanism was required to meet costs of medical care for the elderly, children under five years of age and pregnant women following a recent directive by his ministry to all institutions to ensure that patients in these categories did not pay for basic health care.

“The main challenge for implementation has been availing commodities and equipment in the face of low budgetary support. It is true that some mechanism must pay for this service when it is eventually availed as free service to the identified patients,” said Dr Gwinji.

Dr Gwinji said Government, together with its partners, had over the years strategised and built support for the care of children under five years and pregnant women. He said the main issues in addressing these challenges had always been provision of medical commodities.

“The Health Levy, dedicated to commodities like medicines and surgical sundries, has come in to further strengthen this position,” said Dr Gwinji.

He said this year, the health sector also got a better budgetary allocation compared to previous years, which he said would enable the free user-fee policy to become a reality.

“Putting all this together, we feel we have gone over the threshhold where we really can support the categories (the elderly, pregnant women and children under five) with access to service as per Government policy,” he said.

Medicines, vaccines and other consumables worth over $11 million have already been ordered. Dr Gwinji said Government would however continue to advocate for adequate funding for social welfare to enable the health sector to effectively assist other patients outside these categories but were unable to meet the costs of medical care.

Dr Gwinji said going forward, if the current health financing policy was supported, it could create further opportunities for sustainable health care financing through diverse sources of revenue spelt out in the policy. The health financing policy gave birth to cellphone taxation and has other suggestions for mobilisation of domestic financial resources.

Health institutions contacted for comment on the scrapping of the user-fee policy said they had already effected the directive. Harare Central Hospital chief executive officer Mrs Peggy Zvavamwe said: “So far, everything is going on well and we have been assured that we will also get extra allocations to cover costs of these identified patients, who are no longer paying for medical care.”

She concurred with Dr Gwinji that medicines and medical sundries consumed the bulk of their budgets and that should Government meet these costs for the vulnerable groups, the burden would be lighter for health institution in the country. Community Working Group of Health executive director Mr Itai Rusike said while the free user-fee policy had always been in place, its implementation got mixed at various levels of care.

He said in some instances, patients would receive free consultation fees but would have to pay for medicines or other required services. Mr Rusike implored Government to increase funding for health including grants, for the country to effectively implement its policies.

Paidamoyo Chipunza Senior Health Reporter January 5, 2018

HARARE – Public hospitals could be driven towards the brink of closure through the implementation of a long-standing government policy compelling them to offer free treatment to expecting mothers, children under the age of five, and citizens above the age of 65 years.

This follows a recent directive issued by the ministry of Health and Child Care to all public health institutions that had hitherto been allowed by the administration of former president Robert Mugabe to recoup all their expenses from patients regardless of age or special condition in order to stay afloat.

But with elections around the corner, President Emmerson Mnangagwa’s government has dusted the files by enforcing the policy under the guise of implementing the ministry of Health’s 100-day action plan.

Health experts are, however, alarmed by the directive.

They feel there is urgent need to first secure funding to subsidise the public hospitals that were generating essential cash flows from hospital fees levied on expecting mothers, senior citizens and children under the age of five.

In the absence of government support, they warned that patients could in the end pay a heavy price for it since the levels of health care in public institutions could further deteriorate, leading to the possible closure of some of the facilities.

Community Working Group on Health executive director, Itai Rusike, said the major impediment towards the implementation of the long-standing policy had always been lack of resources.

“We can only achieve this if we increase the domestic funding towards health and increase the budget allocation to at least 15 percent of the total budget as required by the Abuja declaration,” he said.

“The health sector used to be second after Education (in terms of budgetary allocations but) now it has been relegated to number five,” Rusike told the Daily News.

Rusike said there was real and present danger that most facilities could be forced to close if additional resources are not found to bridge the funding gap.

“So what we need is action not just talk. Yes we welcome the directive because it will promote health-seeking behaviour among the population but there is also the danger that there won’t be quality services,” he added.

In the 2018 National Budget, Finance minister Patrick Chinamasa allocated a measly $454 million towards the health sector, against the required $1,3 billion.

Out of that vote, $297 million is expected to go towards employment costs while and $119 million would be for operations and maintenance.

To bridge the gap, government is pinning its hopes on a $239,6 million support from development partners.

In his budget analysis, Prosper Chitambara, an economic expert, averred that not much was being done to guarantee quality of healthcare.

“Per capita health allocation stands at about $30 in 2018 up from $22 in 2017 and about US$24 in 2016. The inadequate public financing of health has resulted in an overreliance on out-of-pocket and external financing which is highly unsustainable,” he argued.

“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 $146. Per capita health allocation is $650 in South Africa, $90 in Zambia and $200 in Angola.”

Most government programmes are being supported by development partners through initiatives such as Resource-based Financing and the Health Development Fund.

Rusike said it was not sustainable to continue relying on donors since some of the programmes will be coming to an end.

He said it was more sustainable for government to consider introducing a national health insurance scheme where everyone contributes.

The Zimbabwe Association of Doctors for Human Rights said government should increase its investments into the health sector.

“No woman should die while giving birth. Increasing access to care by limiting barriers that is user fees et cetera by pregnant women should be coupled with increased investment in the sector by the government,” the association said on its Twitter account.

The issue of free user fees dates back to 1980 when Zimbabwe gained its independence from Britain.

Back then, it was easy to implement the policy because it was backed by an Act of Parliament.

At the time, the policy also covered workers who were earning less than ZW$150 per month and could not afford paying for health services.

In order to cushion the health institutions, government used to release a subsidy to the Department of Social Welfare, which was billed by hospitals providing services to the under privileged.

It was also the trend back then for health facilities owned by local authorities and churches to receive grants from international partners to enable them to provide services to vulnerable groups.

However, these have not been getting any grants for the last 20 years or so.

When the situation in public hospitals turned ugly, government made a complete U-turn on the policy to enable them to recoup their expenses from patients.

Interestingly, towards the 2008 elections, the populist government of Robert Mugabe made another policy change.

It was announced that there would be free treatment for under-fives and those over 65 without any Act of Parliament to support the directive.

This resulted in a situation whereby mothers were detained at hospitals for failing to settle their bills.

In the case of citizens above 65 years of age, while there were not asked to pay for admission fees, they were made to pay for other services such as the cost of x-rays.

The year 2018 brings high expectations of resurgence — politically, socially and economically, with Zimbabweans’ hopes buoyed by the ushering in of a new dispensation led by President Emmerson Mnangagwa.

For Zimbabwe, this year should see free and fair elections, improved health sector, enhanced agricultural production and social services delivery. Political analyst Mr Eldred Masunungure said the new political dispensation and new leadership had brought major expectations from the populace which the Government was expected to fulfil.

“It is, however, impossible to fulfil all the expectations within a short period, but already we have seen major changes within the health sector. The major expectation is free and fair elections. The new President has already spoken of free and fair elections and we hope the election process will produce tangible and uncontested results,” he said.

Mr Masunungure said many people in and out of Zimbabwe and even the diplomatic corps and international financial institutions are looking forward to robust re-engagement discussions.

“We hope the issue of elections and delivery of social services will be on the zanu-pf leadership goals and manifesto. We expect improvement in education and the health sector, which was on the verge of collapsing. There has been shortage of drugs and personnel. We expect a quick turnaround.

“We are grateful that already user fees have been scrapped on hospital charges for children under five, maternity and elderly patients and we hope things will continue to improve in the health sector. We also expect physical infrastructure — the state of roads should be improved and the projects to rehabilitate roads should be completed,” he said.

Stakeholders in the agriculture industry are optimistic of the year 2018. Zimbabwe Farmers Union director, Mr Paul Zakariya said the appointment of the new minister of Lands, Agriculture and Rural Resettlement, Chief Air Marshal Perrance Shiri (Rtd) was a welcome development.

“The minister has already given hope to the agricultural industry by calling for stability on farms and encouraging both local and foreign investment. Practical measures have been made also to create space for active involvement of the private sector in the industry.

“Attention is being given not only to crops, but support has also been extended to livestock sector as well. Government has launched Command Livestock programme and farmers are very expectant,” he said.

Mr Zakariya said the development of local markets through the resuscitation of Cold Storage Company would play a major role in the commercialisation of small holder agriculture. He said there was huge potential to grow the sector and the inclusive approaches that were being encouraged by Chief Air Marshal Shiri (Rtd), if followed through, would certainly bear fruit.

“Agriculture remains the backbone of the economy with very other industry deriving its life from that sector,” he said.

Agriculture economist, Mr Midway Bhunu said stakeholders in the sector were expecting the finalisation of the land audit to put land to production.

“We also expect finalisation of land tenure issues, bankability of 99-year leases and issuance of leases to farmers. There should also be policies to promote investment in cash crops — tobacco, cotton, coffee and horticulture. Prompt payments to farmers under Command Agriculture should also continue in 2018,” he said.

Community Working Group on Health executive director Mr Itai Rusike said civil society was looking forward to seeing efficient use of resources allocated to the health sector by plugging the leakages. He said these leakages should be plugged through strengthening health governance structures and improvement of accountability and transparency.

“We expect to see a functional public health delivery system from the current broken health services that the people can trust and have confidence in,” said Mr Rusike.

He said Government should also finalise the Public Health Act Amendment Bill, which has since been gazetted for debate in Parliament. He said the loopholes in the current Act have seen local authorities such as the City of Harare taking advantage by pumping dirty water to the residents without facing any consequences.

“We expect to see the health sector moving towards realisation of universal health coverage and not leaving anyone behind through prioritising domestic health financing, acknowledging and recognising the role of community health workers, access to essential medicines and having a clear user fee policy backed by law and adequate resources,” said Mr Rusike.

In line with universal access to health, Government has since scrapped hospital fees for infants, senior citizens and pregnant women. The cost of blood has also been revised downwards to $50 a unit with effect from today. The Zimbabwe Republic Police recently admitted to inadequate supervision and unbecoming behaviour of some members as having eroded public trust, faith and confidence in the force.

Addressing senior officers in Harare, Acting Police Commissioner-General Godwin Matanga said they would not hesitate to resuscitate the National Development Committee and to empower the Inspectorate Unit to enhance supervision of police activities at all levels.

Godwin Matanga

“There is a well-known Shona saying that, ‘kugona chivi kuzvituka’. May I therefore urge all of us to self-introspect, accept that our challenges emanate from lack of inadequate supervision and unbecoming actions by some of our members, which have no doubt eroded public trust, faith and confidence in the police service,” he said.

“The young police officers need our constant and regular guidance so that they do not stray and malign the good name and image of the police service.”

Acting Comm-Gen Matanga said refresher, developmental and induction courses would be conducted with renewed vigour so that all officers have in-depth knowledge of police work. Customer satisfaction, professionalism, respect, courteousness and restraint, Acting Comm-Gen Matanga said, would be the epitome of all police activities.

CWGH Analysis of the 2018 National Budget Health Implications

ZIMBABWE will this year spend a measly $25 per person on health, while government expenditure on health continues to fail to reach the 11,3% of Sub-Saharan Africa’s average, and 15% of the national budget as stipulated by the Abuja Declaration.
BY VENERANDA LANGA
The amount of $25 that government will spend on each person this year is a drastic drop from $62 per capita in 2013 (World Health Organisation statistics) which government spent per person, and $58 per capita in 2014, as well as $48 per capita in 2011.
The figures show that health allocations per capita in Zimbabwe have drastically dwindled in the past years.
Community Working Group on Health (CWGH) executive director Itai Rusike, in a post-budget analysis, said government allocations on health had continued to be low (7,7% of the total health budget).
This, however, is a slight increase from 6,7% in 2016, but it is still inadequate as the health infrastructure needs serious rehabilitation, as well as the acute shortage of drugs that patients experience at health institutions in the country.
In the 2018 National Budget statement, Finance minister Patrick Chinamasa allocated $408 million to health, while more money was allocated to Defence ($420m), Home Affairs ($435m), Lands and Agriculture ($497m), and the highest allocation went to Primary and Secondary Education ($905m).
“Per capita (per individual person) health expenditure in the country is insufficient to guarantee adequate access and quality of healthcare as per capita health allocation stands at about $25 in 2018, up from $22 in 2017 and about $24 in 2016,” Rusike said.
“Per capita health spending is $650 (US dollars) in South Africa, $90 in Zambia and $200 in Angola, and the inadequate public financing of health has resulted in an overreliance on out-of-pocket and external financing which is highly unsustainable.”
As a result, government would continue to rely on donor funding with development partners expected to pump in $239,6m, with Global Fund injecting $173,8m, Health Development Fund ($58,1m), and Global Alliance for Vaccines and Immunisation ($7,7m).
While Zimbabwe continues to fail to fund health care to the Abuja convention stipulations, other countries like Malawi, Rwanda, Madagascar, Togo and Zambia have managed to reach the Abuja
target.
“In Rwanda and Uganda, they drastically reduced defence and security budgets in recent years to allow for scaling up of pro-poor expenditure on human and infrastructure development. Military and security spending have been shown to retard development by diverting government resources that could be put to better use. In fact, development, not military deterrence, is the best strategy for a safer society,” Rusike said.
He said developed countries spend relatively more on health, while poor developing countries like Zimbabwe spend relatively more on defence.
Zimbabwe spends about 6% of gross domestic product (GDP) on defence and security and only 2% on health.
“The United States spends 6,6% of its GDP on health care and only 3,8% of its GDP on defence. Japan spends 1% of its GDP on defence and 6,5% of its GDP on health care. Germany spends 1,4% of its GDP on defence and 8,6% of its GDP on health. Eritrea, on the other hand, spends 19,4% of its GDP on defence and only 3,2% of its GDP on health,” Rusike said.
He said while there was a slight improvement in the 2018 health allocation, it was still inadequate to cover the health needs of Zimbabweans.
Health minister David Parirenyatwa recently said he needed over $1 billion.