A perspective on Zim's health delivery system

HARARE - Healthcare delivery system remains a major concern. Is healthcare affordable and accessible? Building a sustainable healthcare system that is within the reach of all is critical.

Healthcare delivery involves access to health facilities, clean water, medicines and proper sanitation among other things. A health delivery system is the organisation of people, institutions, and resources that deliver health care services to meet the health needs of the nation, sometimes referred to as healthcare system. 

An effective healthcare delivery system results in reduced healthcare costs, better patient outcomes and reduced medical complications across a variety of clinical specialties. Successful policy programs drive greater workforce productivity and better use of scarce financial and human resources. 

Zimbabwe’s healthcare system consists of public sector (70 percent), private sector and providers (30 percent).

Unfortunately there are disparities in access and costs worsened by the poor functioning of the public health system.

A strong inclusive healthcare environment is a prerequisite for sustainable economic development because a healthy population is more productive.

Before 2000, our healthcare delivery system was a model for Africa. Presently unemployment is reported at above 90 percent.

According to the ILO those in the informal sector earn less than US$200 per month presenting direct implications on their healthcare needs. Those in formal employment constitute about 10 percent. This affects healthcare delivery access and affordability.

The majority of Zimbabweans rely on public healthcare at a time it is underfunded and receiving just 8,3 percent of the national budget over the years.

While the 2019 allocation is 8,6 percent it is still below the 15 percent Abuja Agreement (2001) and also below sub Saharan countries average allocation of 11,2 percent. 

Individuals must dig deeper into their pockets to purchase medications that are not always available at the public health institutions as a result healthcare constitutes a significant portion of household expenditure. 

The government is committed to Agenda 2030 and the Millennium Development Goals (MDGs). 

Goal number three focuses on good health and that access to health is a basic human right. According to the constitution healthcare is a right of every Zimbabwean. 

In this context much more must be done. Since 2000 there has been reduced healthcare investment, escalating healthcare costs, poor service delivery and dilapidated infrastructure and equipment. 

Earlier gains of the eighties in health delivery have reversed. Under these circumstances the vulnerable must be protected.

The existing structure, conduct and performance of our health delivery system makes it difficult to protect vulnerable groups. 

Even those on medical aid and insurance schemes are not getting the full value and benefit from their contributions affecting confidence in healthcare delivery. 

Who is accessing healthcare?

Previous reports show that 10 percent of Zimbabwe’s population has access to medical aid and insurance schemes with the remaining 90 percent having no access. 

Does the public healthcare system have capacity to cater the 90 percent not on medical aid and insurance?

The 2019 budget appears to have omitted a vehicle through which these be formally integrated into the healthcare delivery.

Conversations on the National Health Insurance Scheme must be accelerated.

Adopting a National Health Insurance Scheme provides health equity. 

90 percent of public healthcare institutions lack essential medicines and consumables.

Patients have to buy these from private pharmacies whose pricing is excessive because of three-tier pricing regime.  

Government’s role over allocation and utilisation of resources is crucial.

Zimbabwe’s health expenditure per capita in 2017 was only US$24 down from US$115 in 2014, the lowest since 1980 although it has improved from US$31 in 2018 to US$41 in 2019.

This statistic is low, revealing an unhealthy nation. 

We have already seen various initiatives for example the 2 percent on mobile platform transactions. 

The benefit of tax funding in healthcare allows people who cannot pay for care to receive it.

Unfortunately, Zimbabweans are already overtaxed. While the Aids Levy revenue taxed on formally employed people has been a success job losses have reduced collections. 

More reliance has been on development partners. In 2017 development partners disbursed US$279 million against government’s budget of US$249 Million.   

In South Africa private medical aid schemes fund healthcare for about 16 percent of their population and 84 percent being tax funded. This is possible for a strong economy unlike our case.

These schemes are difficult to implement in weak informal economies because collections are pivoted on substantial and consistent revenue streams which the informal sector lacks. 

Generally African countries need to show greater commitment towards paying for their health. Countries that have increased investment and reforms are showing improved health outcomes.

Low commitment towards healthcare prompted the adoption of the Abuja Declaration as a prescriptive measure.

Member states pledged to increase their health allocations to at least 15 percent of the country’s annual budget in order to attract increased health support from Western donor countries. 

Already, six African countries have been applauded for meeting the Abuja Declaration.

Rwanda has surpassed this 15 percent benchmark and now allocates 24 percent of its budget to healthcare.

Developed countries finding it difficult to keep up with rising healthcare costs have not cut their health allocations.

Healthcare is highly political and prioritised. According to the World Health Organisation the average total health expenditure in African countries stood at US$ 135 per capita in 2010 a small fraction of US$ 3150 spent on health in an average high-income country. For Zimbabwe the per capita health expenditure was US$24 in 2016 compared to US$593 for South Africa and US$7 285 for the United States of America.

 

Comparative performance

Zimbabwe has 1,6 doctors and 7 nurses and midwives per 10 000 people, reports reveal that 98 percent of drugs and medicines used in public health centres are donor funded.

The Institute of Health Metrics and Evaluation put Zimbabwe’s maternal mortality ratio in 1990 at 185,8 deaths per 100 000 live births, rising to 840,9 in 2003 and then dipping to 520,7 in 2013. 

More recent estimates put it at approximately 614. According to the Institute’s estimates, Zimbabwe falls in the category of only 16 countries worldwide that have a maternal mortality ratio above 500. 

At between 8,3 and 10 percent of national budget allocation to health over the years Zimbabwe is still way below the required 15 percent In 2017 allocation to health was just 7 percent,  8 percent in 2018 and 9 percent in 2019.

The budget allocation should be the first sign of commitment towards a better health delivery system leading to greater equity, economic return, and social stability. 

We advocate a new strategy and focus to avoid further decline of healthcare. Failure of this leads to outsourcing health care outside and puts pressure on already meagre foreign currency.

South Africa allocates 14 to 15 percent to health compared to 11 percent by most African countries. Zimbabwe has over the past 2 years allocated an average of 8,5 percent. In ratio terms South Africa allocates compared to Zimbabwe. 

Globally, health expenditure per capita has been rising over the years. In China it was US$64 in 1995 to US$731 in 2014, India from US$60 in 1995 to US$267 in 2014 and South Africa from US$555 in 1995 to US$ 1 148 in 2014.

Zimbabwe’s has been low, US$115 in 2014 reducing to US$24 in 2016 although rising to US$31 in 2018 and US$41 in 2019. The comfort lies in being above the minimum target of US$34 stipulated by the World Health Organization.

Zimbabwe Public Expenditure notes of 2011 show that 90 percent of the central government transfers to health go to finance curative services with just 10 percent going towards preventive services, and almost no resources are available for research.

This has not changed. It is not just about resources but how these resources are allocated and utilised demanding review of existing systems, structures and responsibilities.    

In 2016 Health had the 4th largest vote of US$321 million representing 8,3 percent of the national budget. In 2017 the allocation outside development partners was lower at US$282 Million and US$490 million in 2018.

Zimbabwe’s per capita allocation of US$31 to US$41 is significantly lower than its regional peers whose average is US$146.

The positive news is that the US$695 million allocated to health in 2019 budget is the highest compared to previous allocations.

This excludes US$240 million expected from development partners.