Call on govt to revise health staffing system, employ qualified personnel
October 14, 2015 in Health, National, News
The government should revise its outdated health staffing system and consider the employment of qualified health workers currently sitting at home due to the current freeze on employment.
By Phyllis Mbanje
The Community Working Group on Health (CWGH) said the existing staff establishment does not address the shortage of health personnel in the country.
CWGH director Itai Rusike said the existing staff establishment was not adequate to address the increasing disease burden, population and emerging health threats as articulated in the World Health Organisation’s building blocks for health systems.
Rusike said the growth in population and disease burden necessitated an increase in both numbers and capacitation of health care workers for the provision of sufficient and quality health care services.
“CWGH noted that in some rural health facilities, when the only nurse available goes for a workshop, the clinic is closed,” he said.
Under the current establishment, 23% of all provincial and central hospitals do not have dentists, while most district hospitals do not have the four doctors required.
Some district hospitals were also manned by pharmacy technicians instead of the required degreed pharmacists.
“We also propose that for any staff establishment posts that have been made redundant as a result of advances in healthcare or changes in disease and demographics, be used to a create a new health cadre,” Rusike said.
In their input statement for the national health budget for 2016, CWGH also said there was need to come up with a funding mechanism for the non-communicable diseases (NCDs) which are costly to diagnose and manage.
The Public Health Advisory Board once proposed introduction of earmarked sin taxes to fund NCDS.
Currently, only 9% of the health workers have been trained in managing injuries, trauma and other priority NCDs.
For diabetes management, only 53% of the health workers are trained to manage the disease.
“The proposal by the Advisory Board should be followed through to avoid premature deaths,” Rusike said.
Stakeholders have previously called on the government to increase budget allocation for health and meet the Abuja Declaration of allocating 15% of the national budget to healthcare.
“Countries that are honouring the convention have done remarkably well in improving their overall health outcomes and status,” Rusike said.
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.
October 23, 2015 in National, News
Over 3 000 nurses in the country are not employed at a time most health facilities are operating with skeleton staff, Health Services Board (HSB) chairman Lovemore Mbengeranwa has lamented.
By Phyllis Mbanje
Speaking at the Community Working Group on Health (CWGH) annual conference in Harare on Wednesday, Mbengeranwa said while Treasury had no money to employ more health personnel, the country was facing a critical shortage of nurses.
“There is need to increase the health budget because how can the posts be filled up when Treasury cannot pay them?” Mbengeranwa queried.
The Abuja Declaration states that governments should allocate 15% of their national budgets to health, but Treasury has been falling short on that lately.
Thousands of nurses left the country for greener pastures at the height of the economic crisis between 2005 and 2009.
Most public health facilities were left with skeletal staff and the situation was worsened when the government put a freeze on recruitment, leaving thousands of nurses stranded upon completion of their studies.
Other stakeholders who had gathered for the CWGH conference also raised concern over the problem which was common at most health facilities.
Director of the Women Action Group, Edinah Musiyiwa, challenged stakeholders to question the detaining of women who fail to pay for maternity fees.
“At policy level, user fees for pregnant women have been scrapped, but at the hospitals, it is a different issue. Someone should question that,” she said.
“The maternal mortality rate is still high at 614 deaths per
100 000 live births and such issues of user fees are some of the reasons women end up giving birth at home.”
Recently, the Harare Residents’ Trust reported that women were being detained at Harare Central Hospital after failing to pay for maternity services.
November 2, 2015 Local News
Public health institutions continue to be dogged by a serious shortage of personnel, leading to low levels of service delivery. The situation is further complicated by a decision by Government to build new hospitals across the country although it has frozen recruitment of health workers. Health Services Board chairperson Dr Lovemore Mbengeranwa confirmed the challenges recently.
He told a Community Working Group on Health annual general meeting held in Harare that staff was being moved from existing health facilities to new ones, leading to serious understaffing. “I am sure you are all aware that we need Treasury concurrence whenever we want to recruit new cadres and it is not always a smooth process to recruit new staff,” said Dr Mbengeranwa.
He said there were more than 3 000 unemployed but qualified nurses on the streets and that there was no hope that they would be employed anytime soon. “The situation has not changed but we continue to negotiate with Treasury for opening of more posts so that we absorb all the nurses,” said Dr Mbengeranwa. He said owing to the increased population and disease burden in the country, there was need for more staff in health facilities.
Dr Mbengeranwa said Government, with support from development partners, was working on a survey to ascertain the actual number of nurses or doctors required at each facility at a given time. The last review of staff requirements in the health sector was done in the 1960s.
Nurses Association of Zimbabwe (ZiNA) president Ms Regina Smith urged Government to speed up reviewing of staff compliments and come up with ways of absorbing unemployed nurses. Ms Smith said ZiNA was concerned that the unemployed nurses would have to undergo retraining when they eventually get employment.
“Government should quickly find ways of absorbing the unemployed nurses because if they continue roaming the streets, they will have to undergo retraining, which is very frustrating than the actual training,” she said.
October 21, 2015 Local News
Government should engage in wide consultations on the National Health Insurance Scheme (NHIS) before implementation to ensure its successful rollout, Community Working Group on Health (CWGH) executive director Mr Itai Rusike has said.
Speaking at a science café on Domestic Health Financing organised by the Health Journalists Association of Zimbabwe (HeJAZ) in Harare yesterday, Mr Rusike said the NHIS was a noble initiative but Government should embrace stakeholders’ input for its success.
“We hope once approved, the Ministry of Health and Child Care will not rush to roll it out nationally without proper consultations. It’s a brilliant initiative with a potential to assist the majority of Zimbabweans failing to access health services because of cost barriers,” said Mr Rusike.
Mr Rusike said civil society does not have faith in the proposal that the National Social Security Authority (NSSA) should administer the fund because of its history on investing in failed banks, giving paltry benefits to pensioners and current scandals that have led to the dismissal of its senior management.
“We do not know how far the ministry (Health and Child Care) has consulted with regards to its implementation but we strongly feel it should take a lead in its implementation instead of the proposed National Social Security Authority (NSSA),” said Mr Rusike.
He said although there was need to mull local sources of funding for health, issues of accountability and transparency to those local sources should not be overlooked.
Citing the example of the National Aids Trust Fund, Mr Rusike said there was need for the National Aids Council (NAC) to revive its initial structures which stretch down to the village level to ensure transparency.
“When NAC was in the embryonic form, they used to have structures down to the ward level but all these structures no longer exist. The structures now end with the district action Aids co-ordinators. Who then is NAC accountable to?” said Mr Rusike.
He also urged Government to take seriously yearly reports produced by the Auditor-General, Mrs Mildred Chiri, on the health sector.
“We are yet to see anyone arrested from the results of forensic audits produced by the Auditor-General year in and year out. This is what contributes to effective use of available resources,” he said.
Speaking at the same occasion, planning and donor co-ordination officer in the Ministry of Health and Child Care Mr Gwati Gwati said there was need for contingent measures to health financing in Zimbabwe as the sector was largely donor-dependent.
Mr Gwati said Government has completed work on earmarked taxes such as taxing alcohol, tobacco, mobile communications, mining and value added tax on certain products.
“This evidence (that the country can raise money locally through these initiatives) is yet to be presented to Cabinet by the minister but all work has been completed,” said Mr Gwati.
He said these taxes would enable the health system to put resources together and respond to the health needs of the country.
Zimbabwe is a signatory to the April 2001 Abuja Declaration which recommends at least 15 percent of countries’ national budgets to be channelled towards health.
However, since adoption of the declaration, the country has never surpassed the Abuja target with the highest allocation so far being 12,3 percent allocated in 2011.
Other allocations range between 6 and 9 percent of the National Budget.
These allocations fall far short of the World Health Organisation (WHO) per capita recommendations of $34 as they range between $12 and $29.
According to Natpharm – Government’s sole drug supplier – over 70 percent of drugs in stock are supported by donors.
BUDGET INPUT – HEALTH SECTOR 2016
The Community Working Group on Health (CWGH) is a network of community/civic based organisations whose aim is to collectively enhance community participation on health in Zimbabwe. The formulation of the National Budget is one area that the CWGH noted required the greater input of the community who happen to be the tax payers. Traditionally the National Health Budget has been formulated by the technocrats at the ministerial level without the direct input or suggestions from the community. Over the years CWGH has been increasingly advocating for community involvement in budget formulation. Community participation in health matters and budget formulation gives a greater depth to the discussion and understanding of the health issues in the country and facilitates achievement of the country’s overall health goals.
The principle that health is a basic and a fundamental human right can never be overemphasized, 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. Community participation matters and health financing, including the budget formulation process gives a greater depth to discussion and understanding of the health issues in the country and facilitates appreciation and therefore achievement of the country’s overall health goals. It is heartening to note that the country has enshrined the individual right to health in the new constitution.
The Ministry of Health and Child Care’s mandate in line with the national vision states that “The Government of Zimbabwe desires to have the highest possible level of health and quality of life for all its citizens, attained through the combined efforts of individuals, communities, organisations and the government. The vision will be attained through guaranteeing every Zimbabwean access to comprehensive and effective social services”. It is this vision which guides our beliefs and values as a community based organization that promotes primary health care philosophy and approach; hence the annual submission of a position paper on the national budget.
The Current Health System Status
Zimbabwe’s public health system provides a comprehensive package from primary to quaternary level services. The primary level is the clinic or health facility and rural hospital with a few admission beds, referring to the secondary or district level where there are at least 3 doctors, and theatre facilities, to the provincial level with 2 or more specialists, and the quaternary level which is the central hospital, with all services including training of high level professionals. The public health delivery system comprises central government, local government and church related hospitals, the latter two being grant aided, (annual support grants and personnel costs) and providing the health services as a delegated mandate from the MOHCC. In the 1980s and 90s the country had one of the best primary health care service models in Sub-Saharan Africa. However, over the years these gains in primary health care have been eroded by a host of factors, and chief among them the inadequate funding of health from the central government. For
example 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 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 10 km 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.
Overview of the Burden of Disease
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. The country has struggled with a huge burden of disease, oftentimes referred to as quadruple in nature. That is, the high burden of tuberculosis, malaria, HIV and Aids, the other communicable disease – cholera typhoid and other epidemic prone disease, the Non-Communicable diseases, and the neglected tropical diseases. It has seen a sharp increase in the general mortality. However in other areas
that are mainly funded by external partners such as Maternal and Child Health have seen a steady improvement in health status as mortality rates have gone down (Figure 1), while those that are not such as NCDs remain an albatross around the MoHCC’s neck as shown in the panel of figures below (Figure 2).
Figure 2: Burden of Disease Communicable and Non-Communicable Diseases
Communicable diseases still remain a cause for concern for the country. They still account for over 62% of overall mortality in the country. HIV and AIDS remains one of the leading causes of burden of disease in Zimbabwe. The current leading causes of death are HIV and AIDS followed by lower respiratory infections, diarrheal diseases and neonatal and preterm births. While the current causes of morbidity and years of life lost as result of disability are HIV and AIDS, low back and neck pain, depressive disorders iron deficiency anaemia and skin diseases.
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
Over the last 15 years the economy has suffered immeasurable damage. Its domestic and foreign debt has grown to unsustainable levels affecting the country’s ability to attract the much needed international finances. Agriculture production for most essential commodities, except for tobacco has gone down affecting the food security and livelihoods of a lot of households. The advent of dollarization made it even worse as the country became uncompetitive on the international market. Although prices of essential commodities and health services have began to go down as evidenced by the current deflation, most still remain priced beyond the majority of the people in
the country. Household food security has been negatively by poor harvest yield of food commodities. The poor performance of the economy has also led to the closure of a number of companies in all sectors of the economy. This has culminated in the reduction of aggregate production and loss of work, and this has in turn negatively affected both the government’s finances and the general social welfare of the people. The few remaining operational companies are currently restructuring and rationalising their workforce leading to massive job losses and the
resultant massive social problems. These job losses have exacerbated an already precarious situation as regards the health status of the population. Against this background we continue to witness rising Out-of-Pocket (OOP) expenditures for health and a generally low level of utilisation of health services by most households at a time when they need the service most. Chronically ill patients who require constant supplies of expensive medications have been hit hard. Studies on financial and benefit incidence analysis have shown that the poor household and
vulnerable population groups contribute relatively more to taxes, but get relatively low health benefits and disproportionate access to critical health services*.
Overview of the Health financing
During the 1980s and 1990s, the government funded the bulk (up to 90%) of the country’s health care needs. Funding was also relatively adequate in the urban areas, but not quite so in the rural areas. However, for the past fifteen years patients or households have borne the burden of paying
Institute of Health Metrics and Evaluation, country profile for Zimbabwe 2013
Page 5 of 16
CWGH Input into the 2016 National Health budget
for health care through OOPs, while the external partners have increasingly contributed to the
bulk of public financing for health services in Zimbabwe.
The current National Health Accounts show that patients, through OOPs account for 39% of the
Total Health Expenditures (THE), followed by the private sector expenditures with 24%,
external partners with 19% and government with 18%. External partners
through the Global
Fund, the Health Transition Fund (HTF), PEPFAR and GAVI continue to provide the bulk of the
public health financing. About 98% 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.
External partners also continue to provide critical medical equipment at both the primary and
secondary levels of care in order to strengthen the country’s primary healthcare service delivery.
Although external partner funding and support is channelled off-budget
, most of the funding and
commodity support goes through established government entities in order to sustain them and
strengthen their capacities. For example, most of the drugs pass through the National
Pharmaceutical Company (NatPharm), which gets paid some nominal fees for storage and
distribution fees. These have continued to support its operations against a background of low
funding from the government. The government of China has also supported the MoHCC with a
loan of over US$89 million. The loan has largely been in the form of provision of critical
hospital equipment. However, in the medium to long term over-reliance on external partner
support will be counter productive. The government needs to therefore increase its domestic
funding as this financing mechanism has always proven to be sustainable. In view of all these,
whichh we feel have contributed to non- achievement of the Abuja targets and the soon to be
reported MDGs, therefore threatening the achievement of the SDGs, we have a few
recommendations for consideration in 2016:
USAID, DFID, SIDA, Irish AID, NORAD, European Union, GTZ
Off-budget funds do not pass through the Ministry of Finance for allocation; hence are not reported in the National
Recommendations from CWGH for the 2016 Budget
1. On provision of health services
Page 6 of 16
CWGH Input into the 2016 National Health budget
Staff establishment: A costed new staff establishment needs to be developed by the
MoHCC. The CWGH urges the Government to revise the MoHCC’s 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. The existing staff establishment
is not adequate to address the increasing disease burden, population and emerging health
threats, and this is well articulated in the WHO’s building blocks for health systems
strengthening. 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. For example CWGH noted that in some rural
health facilities when the only nurse available goes for a workshop, the clinic is closed.
However, even with the current establishment levels, the government is still unable to fill
in the current establishment. For example 23% of all provincial and central hospitals do
not have dentist
. Most District Hospitals do not have 4 doctors as is required in the
current establishment. Some district hospitals are also manned by pharmacy technicians
instead of the required degreed pharmacists.
Using old establishment posts to create a new health cadre: CWGH also proposes that
for any staff establishment posts that have been rendered redundant as a result of
advances in healthcare or changes in disease and demographics, be used to a create a new
Strengthening the Referral System: The primary care level needs to be funded fully in
order to also address the non-referrals at the secondary and tertiary levels. The CWGH
also supports the idea of having 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.
MoHCC Bottleneck Study, 2015
Page 7 of 16
CWGH Input into the 2016 National Health budget
Fund for Non Communicable Diseases (NCDs): 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% of the health workers have been
trained in managing injuries, trauma and other priority NCDs. For diabetes management
only 53% 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
Emergency medical services: 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 staff, again leading to
complications and avoidable deaths.
Support for Primary and Secondary Level of Care: A significantly larger share of the
budget should go to the district level to support health facilities and the first referral level.
Basic health infrastructures in urban, informal, resettlement and rural areas need
improvement. While there has been some improvement with MNCH indicators, Infant,
under 5, and maternal mortality rates remain a cause for concern and current rates are still
high compared to the regional estimates and previous country estimates. Poorer
households continue to endure disproportionate losses in infant, child and mortality as
compared to the richer households. CWGH therefore encourages more funding for
primary level care. The current ratio of over 70% funding being allocated for curative
services and less than 10% funding being allocated for preventive services, will not see
the country moving towards reducing further the rates of maternal and child mortality.
2. Selected Programmes
Health Services Outreach: A number of patients are still enduring unbearable long
distances to access primary health care facilities. The Government therefore needs to
MoHCC Bottleneck Study, 2015
Page 8 of 16
CWGH Input into the 2016 National Health budget
increase funding for outreach services so that communities in remote areas and newly
resettled 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.
Results Based Financing (RBF) and the Health Transition Fund (HTF) – At the very
short term the RBF/HTF programmes have improved the health outcomes of a number of
facilities in the country. However, the little amounts for incentives that some clinics are
getting from the RBF remain a cause for concern. Some facilities are receiving as little as
US$20 per quarter resulting in low morale and in the process compromising service
provision. These small amounts have also increased the gap between those facilities that
are receiving more and those that are receiving less. The RBF/HTF programme may need
to further review and refine its incentive system to address some of these discrepancies.
Communities should be involved to better support the health workers and jointly plan for
improved services while advocating for more resources. Tensions between RBF Local
Purchasing Agencies and Health Centre Committees have also developed due to some of
these small awards being given to some facilities increasing the vulnerability of the
facilities and their respective communities.
Vulnerable Populations and Assisted Medical Treatment Orders (AMTOS: While
there are existing government policies to cushion the vulnerable groups from making
catastrophic health payments, there is still insufficient government counterpart funding
for Maternal and Child Care and for the Assisted Medical Treatment Orders (AMTOS)
programme. Government promised the RBF programme US$5 million for this fiscal year
as counterpart funding, but up until now it has not disbursed the full amount. Some
patients have failed to honour their payments often times resulting in institutions
commencing legal proceedings against them (Debt collection and attachment of
household properties). Senior citizens who are exempted from paying user fees are still
paying for other access fees such as ambulance services, blood and medications.
Counterpart funding for the RBF programme needs to be increased in order to cover
some of these unaffordable but critical services. These funds must also be disbursed on
time so that efficient provision of services is not affected.
3. Drugs and Sundries
Page 9 of 16
CWGH Input into the 2016 National Health budget
Essential medicines: For imported drugs, bulk purchasing mechanisms should be
strengthened through supporting NATPHARM. Increased funding to NATPHARM will
enable it to continue to capitalise its operations so that it can increase its capacity for cost
effective bulk procurement, storage and distribution. Availability and distribution of
medicines is still a huge challenge, hence accountability mechanisms of the distribution
chain should also be put in place and monitored by communities and by MoHCC to
prevent leakages of drugs purchased at reduced prices. CWGH therefore supports
increased funding for NATPHARM operations so that patients do not get drug
prescriptions in order to access medications from private pharmacies. Adequate funding
of this critical arm of the health care will enhance and improve availability and its
medicine distribution chain and management and in the process also curtail the growth of
the counterfeit drug market.
Paediatric AZT drugs: The MoHCC bottleneck study estimates only 38% of the
facilities have paediatric AZT. National AIDS Levy Funds, in particular the new funds
directly targeted for district level activities could also be used to improve the availability
all paediatric preparations including of AZT in health facilities.
Blood Products: Blood products have become expensive and inaccessible to many
bottleneck analysis that was carried out by the Ministry of Health and Child Care shows
that 60% of secondary facilities were found to have no blood in their stocks. Some
facilities could not stock blood because of unavailability of fridges, electricity and
general poor infrastructure. There is therefore need for the government to consider other
alternatives such as solar refrigerators for storing blood products. The Zimbabwe
National Blood Transfusion Services (ZNBTS) Company is considering introducing
Nucleic Acid Testing (NAT) for blood screening. The NAT has higher sensitivity and
specificity for detecting multiple bacterial and viral infections than the current
technologies being used. NAT also reduces the window period by which results are
known, making it more cost effective. There is therefore need for government to provide
funding for rental capital or for the procurement of required NAT machines. More
MoHCC Bottleneck Study, 2015
Page 10 of 16
CWGH Input into the 2016 National Health budget
funding will also be needed for ZNBTS to develop a comprehensive national blood
Kits for Emergencies Response: The MoHCC bottleneck analysis revealed that only 16
district hospitals have kits for any emergency response, while only 50% of the staff has
been trained for outbreak detection and response. There is therefore need to assign a
budget for strengthening the country’s outbreak detection, preparedness and response.
4. On Infrastructure and healthcare technologies
Capital Budget and facility rehabilitation: The limited capital budget leaves the
government with little room to provide new infrastructure, carry out major refurbishment
in some and improve the existing ones. Current expenditures have accounted for more
than 80% of the MoHCC budget, leaving inadequate funds for the capital expenditures.
There is therefore a need for the government to increase the MoHCC’s capital budget,
especially the funds allocated for the targeted infrastructure rehabilitation programme.
Health Technologies: Surveys on human resources and Infrastructure have identified
huge gaps in terms of human resources availability and health care technology
availability; there is therefore a need to move towards ensuring that agreed normal levels
and types of human resources are available and financed at the district level, as well as
ensure that the minimum healthcare technology is found at the district level. For example
only 47% of facilities in the whole country have TB diagnostic testing equipment, while
44% of facilities have functional glucometers and strips for diabetes testing and
5. Health Financing
On Strategies for increasing fiscal space: CWGH supports the Government position on
the need to reform the civil service in order to harvest the much needed fiscal space
particular the CWGH supports the rationalisation of wages in line with the current fiscal
sustainability plan agreed between the government its partners; for example the removal
of duplication and redundancies that impact on the overall efficiency of the system and
IMF Country Report April 2015
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CWGH Input into the 2016 National Health budget
the creating of relevant new cadres using the old establishment. CWGH therefore
strongly supports the Government’s commitment to cut expenditures for non-priority
current and capital spending to free funds for other important issues. The CWGH also
supports the effective and efficient coordination of Aid by one single entity so that AID is
channelled where it is needed most.
Honouring the Abuja commitment: A decade and half after Abuja, only 6 countries
(Liberia, Madagascar, Malawi, Rwanda, Togo and Zambia) have achieved the Abuja
Target of allocating at least 15% of their annual national budgets to healthcare. Of note is
Rwanda which spends at least 23.7% of its budget on healthcare, three times more than
what the Zimbabwean government allocated to healthcare for the 2015 fiscal year. For
example 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 government therefore needs to honour the Abuja Commitment and
allocated 15% of the national budget to health.
On-Budget support: Government achieved more favourable health outcomes when it
provided more funding than its partners. It also achieved more health gains for the
population when the partners channelled their funding through its systems rather than offbudget.
This is evidenced by its achievements in the 1980s-90s, a period characterised by rapid gains in the health indicators. For example, the government managed remarkable reduction in infant and under 5 mortality rates. If external financing is channelled through the Ministry of Finance, hence through the National Budget it will reduce parallel systems and increase efficiency in the allocation of the funds.
National Health Insurance: CWGH supports the creation of a National Health
Insurance, and bemoans that this process which could have been implemented a decade
ago remains somewhat non-priority. We urge government to urgently address this matter
and reduce the current high levels of catastrophic health spending, especially given the
fact that the medical insurance industry which at its best only covered up to 20% of the
population has been allowed to rot and throw more households into high OOPs.
World Health Organisation on meeting the Abuja Targets
CWGH Input into the 2016 National Health budget Furthermore, CWGH recommends the management of the proposed NHI be given to the MoHCC instead of the Ministry of Public Service, Labour and Social Welfare. The
CWGH is of the opinion that unlike the Ministry of Public Service, Labour and Social Welfare, and the MoHCC has enough Acts under its portfolio to oversee the smooth running and management of such an important fund. The CWGH also expresses concern on the level of consultations that have been done in coming up with the bill. CWGH
therefore advocates for adequate and inclusive consultations with stakeholders as input into the NHI and a monitoring mechanism be put in place at the outset to ensure this process is not stalled again.
Public-private partnerships (PPPs) – Two notable institutions, Mpilo hospital and Chitungwiza hospitals are good examples of state institutions that have ventured into PPPs, with Chitungwiza hospital recording some key notable successes. For example its partnership with Jet Lab in 2013 enabled it to acquire an endocrinology analyser
equipment then valued at over US$900 000. The hospitals also entered into joint ventures with other private players in the areas of radiology, catering services, mortuary and pharmaceutical departments. While these initiatives are commendable, CWGH notes with concern the slow privatization of these institutions, particularly Chitungwiza hospital. This could in the future negatively affect the provision of services at these institutions. CWGH strongly supports these initiatives and the government’s commitment to PPPs. However these initiatives must strengthen the ‘first P’ rather than the ‘middle P’; thus recommending the strengthening of the Public Health system first so that it can deal with the Private sector from a position of strength. The CWGH also supports the participation of the government and civic organisations in the negotiations of some of these joint ventures and PPPs.
Achieving Universal Health Coverage (UHC): The UHC comprises provision of quality health services through essential health services coverage and financial coverage for the whole population. As the WHO notes, the road to UHC is by no means smooth. Achieving UHC requires capacities in many areas. UHC crosses boundaries, UHC is
multi-sectoral and UHC is a process. UHC requires that the government increases its level of domestic funding to make much greater efforts to reach the Abuja Target, which MoHCC administers a total of 16 Acts – Statutory Instrument 27 of 2014.
Page 13 of 16
CWGH Input into the 2016 National Health budget aimed at achieving 60% then 80%. UHC now requires 100% and requires that the government works towards sustained and innovative financing for health, alongside the
monitoring of key health indicators; cumulative and sustained effort on measures of best addressing the new Sustainable Development Goals (SDGs). Therefore the CWGH encourages the government to honour its commitments in order to achieve UHC.
AIDS Levy: At the beginning of 2015, National AIDS Council allocated US$5 million from the AIDS Levy funds to be distributed equally to all the provinces for various projects. The funds were distributed based on approved operational plans from the various providers of services. However noble this new initiative maybe, there is need to
strengthen its governance and accountability structures so as to curb any mismanagement of these funds. There is also need to develop an equitable method for allocating the funds based on needs, disease burden and other related factors. The MoHCC’s latest bottleneck study estimates that about 43.5% of communities and households have low food security. There are various areas in the country where people on ART need to be provided with food packs.
6. On Governance and Accountability Public Finance Management (PFM): CWGH supports the amendment of the Public Finance Management Act that seeks to increase accountability of government structures.
For example user fees collected by the major Central Hospitals are not reflected in the MoHCC’s budget. This creates loopholes in the management and accounting of these funds. There is need to set aside funds for the training of personnel in PFM.
Findings of the Auditor General: The government has reaffirmed its commitment to
follow up on findings from the Comptroller and Auditor general on ministry
expenditures. The CWGH supports this and urges the Ministry of Finance and in
particular the MoHCC to treat this as urgent and make a follow up on the Comptroller
and Auditor General’s recommendations from the 2014 Audit Report and other previous
audit reports Report Parliament Portfolio Committee on Health, 2015
Corporate Governance Bill: CWGH fully supports the Government’s restructuring of
parastatals through the enactment of the Corporate Governance Bill for strengthening of
its accountability structures.
Independent Board to Regulate Medical Aid Societies (MAS):
We continue to witness the collapse of some schemes, mismanagement of funds and the uncompetitive behaviour
of other MAS leaving their members vulnerable. MAS that have embarked on vertical integration of medical services have negatively affected the services of individual providers of care such as doctors and pharmacists. These single owner operations have been exposed to the unfair competition and uncompetitive behaviour by some of these
MAS. CWGH 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. There is need for stakeholders to support this noble initiative and for the MOF to set aside funding for the consummation of this body.
On Socioeconomic issues
Sustainable Development Goals: The CWGH supports the realization of all the 17 Sustainable Development Goals (SDGs) and advocates for funding to support the realization of these goals. Unlike the MDGs which according to WHO, were often fragmented and led to silo approaches, the SDGs follow an integrated approach, encompassing a multi-dimensional and inter-sectoral approach. The SDGs have a broad set of 13 indicators for health, with other health issues incorporated in other SDGs. It is also encouraging to note that UHC is intrinsically linked to the SDGs with a specific health target; “achieve UHC, including financial risk protection, access to quality and essential health care services and access to safe, effective, quality, and affordable essential medicines and vaccines for all”. For effective realisation of SDGs the country’s economic policies such as the ZIMASSET, the socio-political policies should therefore be used to promote the realization of these goals. The CWGH supports the crafting of realistic and measurable short-medium-to long term targets that can be tracked to assess progress.
Social determinants of health: Health services should strengthen community health systems and work with communities and all other stakeholders to tackle social determinants that drive the epidemics of communicable diseases and hinder access to health care services. Access to safe clean drinking water is a fundamental human right and there is need for wider consultations on the issue of pre-paid water meters as they have a potential of creating a barrier on access to water thereby increasing the risk of diarrhoeal and other waterborne diseases. The need for Zimbabwe to address the social determinants of health becomes more imperative if the NCDs burden is to be addresses.
Water supply: Water supply is a challenge at a number of clinics (RHCs) which do not have proper water supply systems. Heavily pregnant mothers are asked to bring their own water whilst waiting to deliver at these facilities. There may be need for partnerships between private businesses and local authority to ensure there is water supply at health facilities.
Food Security: A deliberate policy to increase the budget of other sector ministries that have direct impact on people’s welfare such as agriculture, mining and transport must be encouraged. At least 10% of the national budget must go towards financing agriculture, specifically the smallholder farmers.
Loss of employment: Loss of employment leading to loss of earnings will lead to a fall in private health contributions. This is likely to cause many of the former workers to use their own savings for accessing care or decide not to access care at all. CWGH notes that the burden of this loss of employment will likely be heavier on the part of patients who were accessing ART using private schemes and those who would be forced to relocate to rural areas.
It is the CWGH’s humble request that these community submissions be taken into consideration when the 2016 National Budget is being formulated.
For further information, please contact:
The Executive Director
Itai Rusike (Mr)
Community Working Group on Health (CWGH)
312 Samora Machel Avenue
Tel: +263-4- 498 692 / 498 983 / 498 926
Cell: +263-772 363 991
Email: firstname.lastname@example.org / email@example.com
Credits: Voice of America
HARARE — The United Nations is reporting huge improvements in Zimbabwe’s prenatal, newborn and maternal health care over the past five years.
However, the U.N. Children’s Fund says the survey indicates that Zimbabwe must continue working to improve health standards.
According to research findings released Friday, Zimbabwe’s infant and maternal mortality rates have declined by 20 and 36 percent, respectively, since 2009.
The number of pregnant women who received prenatal care increased from 57 to 70 percent, while mothers accessing care after giving birth had soared from 27 to 78 percent.
The UNICEF research was funded by the European Union and the government of Zimbabwe.
Much of Zimbabwe’s progress is due to assistance from a multinational fund dedicated to improving health care for mothers, newsborns and young children.
Despite these encouraging results, UNICEF’s chief representative in Zimbabwe, Reza Hossaini, says it is still too early to say all is well with early child care in the southern African country.
“Let us keep in mind that, yes, we have won battles here and there,” said Hossaini. “We have bent the [trends of] maternal mortality, but we have really not won the war as yet. These gains cannot be sustained and further progress cannot be made if we lose our focus from those strategic choices that we have made, now that we know they have delivered positive results.”
Two of those strategic choices were investing in the health sector’s human resources and making sure that the country maintains adequate supplies of necessary drugs.
Failure on those fronts was the major undoing of Zimbabwe’s health sector over the past two decades.
It was only after organizations such as the U.S. Agency for International Development and the European Union poured in money that the situation changed.
Itai Rusike, who heads the Community Working Group on Health, an organization fighting for all Zimbabweans to enjoy health care, expressed optimism about the UNICEF report.
“Generally it is a good report,” said Rusike. “It gives us hope in the sense that the indicators are kind of improving. But this report has to be linked up to what is happening on the ground.”
But he added there a dire need for better water and sanitation in most parts of Zimbabwe persists. More than 30 percent of Zimbabweans still do not have access to safe drinking water, the research showed, and Rusike said the real number is likely higher than that, since most water taps in urban areas are dry.
Dr. Gerald Gwinji, permanent secretary at Zimbabwe’s Ministry of Health, is more upbea, calling the new health report one that gives the country a sense of direction.
“We now have to work on issues of quality and equity,” he said. “These survey results are going to be one of our pillars of our next health strategy, and the next step is to do a bottleneck analysis [of the] ministry of health and child care. This will help to determine where to focus to help further improve on our health indicators.”
Gwinji said Zimbabwe’s maternal mortality rate — 614 deaths in every 100,000 pregnancies — and infant mortality rate of 75 per 100,000 are still too high. He says further investment can reduce those losses.
Credits: Voice of America November 02, 2009 10:26 AM
Cholera infections continue to occur in Zimbabwe’s capital city, Harare, and in the nearby satellite town of Chitungwiza, despite a steep decline in other parts of the country, according to the latest World Health Organization report on the nine-month epidemic.
The WHO reported 105 new cases in Harare, Chitungwiza and the Harare suburb of Budiriro in the five days through Monday, though listing no new deaths. But the Harare region has accounted for 19,232 cases and 653 deaths since the epidemic began in late 2008.
Cases nationally totaled 97,795 resulting in 4,265 deaths from the disease.
WHO attributed the persistence of the cholera epidemic in the capital region to disruptions in the local water supply and continued unhygienic disposal of waste.
Executive director Itai Rusike of the Community Working Group on Health told reporter Patience Rusere of VOA’s Studio 7 for Zimbabwe that the capital region risks another major outbreak of cholera when heavy rains resume in September.