PHA-Exch> Position paper from PHM Zimbabwe for PHA Exchange

[Claudio Schuftan]

From: David Legge <D.Legge at latrobe.edu.au>

 People's Health Movement Zimbabwe: Position Paper: June 2008

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1. Socio-economic background

At Independence in 1980, Zimbabwe inherited some of the worst rural-urban
disparities in the provision of social services. In the 1980s, the new
national government made commendable progress in redressing these
disparities. In healthcare delivery, these efforts resulted in lower
maternal, infant and child mortality rates and improved life expectancy.


  Since the late 1980s, the Government increasingly relied on offshore and
domestic borrowing to fund the national budget deficits. As the debt burden
became increasingly unsustainable, the need for economic reforms became
urgent. However, the resultant economic structural adjustment program
(ESAP), of the early 1990s was marked by the rolling back of the welfare
state, which accelerated the downward spiral in key social indicators.

  At the same time, trade liberalization unleashed competition that further
depressed the local economy. The land reform program exacerbated the
situation at the turn of the new millennium, which led to the demise of
commercial agricultural production, destroying agro-based industries and
adding to the shrinking of the national revenue base for sustaining social
services. Inconsistencies in the management of macro-economic factors during
and after the failed ESAP ensured that the turnaround of the economy
remained an elusive dream as unemployment and poverty continued to rise.

As a result of Zimbabwe's failure to keep up with debt repayment schedules,
the IMF and World Bank have not supported Zimbabwe for much of the new
millennium, and confrontational foreign relations have shut out support from
traditional bilateral and multilateral donors. Against a backdrop of
declining economic productivity, a thriving black market for basic
commodities and the printing of money to meet budget deficits fueled the
rate of inflation, which breached the 160 000% mark by end of March 2008.
For most Zimbabweans, the cost of living has outstripped income-earning
capacity. Meanwhile, unemployment breached the 80% mark by end of 2007.  On
key indicators, Zimbabwe is drifting away from the targets for achieving the
Millennium Development Goals:

• Life expectancy is around 37 years for males and 34 for females, the
lowest in the world, according to WHO

• Primary school enrolment rates are falling, with girls worse off than boys

Zimbabwe has in the past years experienced severe macroeconomic constraints,
with factors such rising poverty levels, a limited capacity to absorb
external price shocks, unstable exchange rates and inflation. These factors
have necessitated the need for long term planning, while also making it more
difficult both to plan for and adhere to expenditure and revenue targets.
For example, for the past 6 years Zimbabwe has had more than 2 supplementary
budgets on account of expenditure overruns by line ministries (EQUINET
Discussion paper 43).

  A better health is an input to economic development and, therefore,
development funding should be mobilized to address diseases such as AIDS and
malaria because these are barriers to economic development. The General
Agreement on Trade in Services (GATS) is one of a number of international
agreements under the umbrella of the World Trade Organization (WTO), the
largest multilateral trade body whose purpose is to liberalize or remove
barriers to trade by promoting the free movement of goods and services,
labour and capital. GATS has been designed to regulate measures affecting
international trade in services, public services included. GATS might have
enormous implications for public services, especially health care services.
Some of these include the inhibition of governments from shaping their own
health care systems, the threatening of government-funded or -provided
health services, the undermining of domestic regulation and the protection
of public health

  Much of this deterioration can be traced to the escalating social
instability triggered by a high HIV/AIDS prevalence and the intensifying
poverty. The link between poverty and the spread of HIV/AIDS is well known,
and it is very disturbing that the incidence of HIV/AIDS infection and
poverty in Zimbabwe is in both cases very high.

2 The Issues: Citizens lack access to quality health care

The massive exodus of skilled health personnel has led to deterioration of
health care services in the public health sector. The cost of health
continues to soar, and we continue to witness unnecessary deaths, deaths
that are highly preventable. CWGH recognizes with concern that sometimes it
is not a question of finding a vaccine or a cure, of brilliant scientists
laboring over test tubes. In many cases, it's not even a question of the
Zimbabwean government having to find huge amounts of cash, but instead, the
government has to prioritise the people's health and make resources
available to enable communities to access quality health care.

Challenges that communities face range from unavailability of drugs and
necessary equipment at public hospitals and clinics. Drugs and services in
the private sector have become very expensive, as Zimbabwe has to constantly
rely on exports since local pharmaceuticals have limited access to foreign
currency. In some instances, villagers living in remote communities have no
access to health care services due to accessibility issues. Most
transporters are grounded due to the lack of fuel and spare parts. Besides,
business is no longer viable for transporters to ferry patients to hospitals
due to the economic doldrums that Zimbabwe finds itself in.

3. The role of the State

3.1 Health Budget


During the Heads of States meeting in Abuja (Nigeria, 2001) a declaration
which was agreed by all Heads of States and coined The Abuja Declaration
(2001) recommended that the Health budget of all member states should
constitute a minimum of 15 percent of the total   government allocations. An
analysis of taking the period 1997 up to date, it can be seen that there has
not been significant improvement in the Government budget allocation to the
Health Ministry. In the last three years the percentage allocation of the
total budget has been averaging around 9.5%

The government spending for health has remained low as it has failed to
reach the Abuja target of 15% of the National budget. Traditionally the
allocations are set out as Line-item budget allocations to health
authorities, programmes and facilities. Specific instructions and
regulations prohibit public administrators from switching funds across line
items without prior approval from the Treasury. Such traditional budgeting
systems do not hold health administrators accountable for ensuring that each
line item is fully expended, but not necessarily for the performance against
that expenditure. This type of budgeting may leads to inefficiencies in
spending patterns that affect equity and to perverse incentives. If, for
example, unspent funds at the end of a financial year are used as a signal
to Treasury that the next period's budget allocation should be cut,
administrators may see this as an incentive to spend their allocations
without regard to efficiency

3.2 Millennium Development Goal

In September 2000 147 heads of State and Government, and 189 nations in
total, in the United Nations Millennium Declaration otherwise known as the
Millennium Development Goals (MDGs) committed themselves to making the right
to development a reality for everyone and to freeing the entire human race
from want. They acknowledged that progress is based on sustainable economic
growth, which must focus on the poor, with human rights at the centre. The
objective of the Declaration is to promote "a comprehensive approach and a
coordinated strategy, tackling many problems simultaneously across a broad
front."

  The Declaration calls for halving by the year 2015, the number of people
who live on less than one dollar a day. This effort also involves finding
solutions to hunger, malnutrition and disease, promoting gender equality and
the empowerment of women, guaranteeing a basic education for everyone, and
supporting the Agenda 21 principles of sustainable development.

4. The CWGH Position

For a country to deliver basic health care to its people, it requires a
fully functional health system. There are many ingredients that make up a
functional health system, including human resources for health, transport,
facilities, medicines and supplies

We recognize the causal relationship between health status and the economy.
We thus appreciate the need for the government to simultaneously revitalize
the health delivery system as it works to rebuild the economy, recognizing
that economic growth will not translate into social growth, unless the gains
made are translated into social development

CWGH advocates for lower out-of-pocket payments and an increase in
progressive tax revenues, encourage universal coverage in Zimbabwe.
Progressive tax revenues are when those with greater ability to pay should
contribute a higher proportion of their income than those with lower income.
The HIV and AIDS Levy is levied at a flat rate of 3% across all income
groups, meaning that the impact of this tax on incomes is felt more by those
in the lower income groups. This puts some focus on how public policies and
budgets can reverse this.  Resources should be allocated in response to
need. Equity in health care financing means that individuals (or families)
contribute resources to

health on the basis of their ability to pay, and receive resources for
health on the basis of their health need

CWGH fights for the accountability of the Ministry of Health to the people.
Pre and Post budget meetings are done with the Parliamentary Portfolio
Committee on Health but there is little room for reflection and giving
feedback to the community. There is need for MoHCW to allow civil society to
monitor and track the budgeting system. Communities at district level do not
know their budget allocation for their district and it becomes difficult for
the health system to be accountable to the people

Our position regarding the health sector in the post election era is based
on the notion that health is not only a rights issue, but also an important
underlying determinant to economic growth. We call for immediate and
holistic approach to health delivery revitalization. We believe that
Efficiency, Accountability and Consumer choice are the cornerstones of our
success; as such these should shape our vision.

4.1 State, non state actors cooperation

We call for varying forms of engagement between the government and non state
players. As much as health delivery is a core responsibility of the
government, but its success and sustenance of gains made calls for concerted
efforts by the government and non state actors, with the government taking
the led. We recommend the re-organizing the health delivery system in
Zimbabwe, so as to come up with a system that encourages civic
participation. State, non state actors cooperation is vital in ensuring that
the health system is not only responsive to the needs and aspiration of our
communities, but will also claim the space to protect and advance public
interests in health in the global environment in the world of globalization
and liberalization.

Partnerships with civic movements and organisations such as the CWGH are
vital in defending public interests in health. Recent models of public
health are calling for greater agency, within a social justice framework, by
communities most affected by public health policy and practice, as opposed
to relying on traditional paternalistic state intervention (An Alternative
to Global Health Report). This serves to increase accountability of the
health sector to the public with ultimate efficiency and appropriateness.
The first step is to establish or restructure health governance boards so
that they are inclusive of civic groups working on health, as a means of
ensuring community representation at all levels. This will increase mutual
accountability and autonomy in the governance of health.

TAC presents a case example on how state-Civil Society interactions can help
safeguard public interests, when it appeared as an amicus curae ("friend of
the court") in support of the South African government, when the government
introduced legislation to allow parallel importation and/or compulsory
licensing of medicines. TAC mobilized huge international protest against the
pharmaceutical companies' for vigorously opposing the legislation (TAC,
2001)

We should however be weary of State-Private Sector partnership as they may
increase the gap between the rich and the poor in health. Such partnerships
should be beneficial to the public and the role of the private players in
health should be closely monitored. Such partnership should be aimed at
benefiting the public and risks of creating inequalities should be
systematically assessed. This is more important to partnerships that come in
the pretext of globalization / liberalization.

4.2 Deconcentration of the health systems

We urge the government to consider deconcentration of the health systems
administration to district health management teams. Deconcentration means
empowering district health teams and more decisions are made at a peripheral
level. We propose the DHS model (WHO 1988, WHO, 1992) as the best framework
for decentralization.  The government should seriously consider the
following key elements of this framework;

* Establishment of District-Level Management teams with the authority and
capacity to manage the comprehensive and integrated mix of community based,
clinic and hospital services

* Facilitate multi sectoral actions on health and to work with local non
state actors

* Introduce the 'New Public Management'- introduce competition between
different public sector departments

* Identifying benchmarks and indicators to ensure monitoring of the
progressive realization of health.

Decentralization of the sector will create an environment that nurtures
equity as marginalized and alienated groups are better identified and the
inclusion of their preferences in health planning and resource allocation is
assured. This should however not be viewed as a means to exonerate
government from its obligation to provide health care. The central
government should continue to manage the resourcing of the health sector and
to give technical support to the peripheral centers. This will create mutual
accountability between the DHTs and central government, and ultimately
efficiency and effectiveness. Decentralization also has an added advantage
of availing district an opportunity to raise local revenue and to mobilize
resources outside the health sector. The need to capacitate district health
teams cannot be emphasized as success is centered on the capacity of each
team.

The current expenditure lines in the MoHCW do not disaggregate spending at
district and at primary care level making it difficult to track policy goals
for and performance of primary health care and clinic services. Major
referral hospitals increased their real expenditures and it would be
important to determine the functioning of the referral system to assess
efficiency in use of allocated resources to these levels.

4.3 Comprehensive PHC

As a Working Group on health we believe that nothing can beat
comprehensiveness when it comes to health care delivery. Our experiences as
a country with comprehensive PHC serves as empirical evidence to the strides
that CPHC can bring in health delivery. The well documented successes that
our nation has gone through in the early years of the Alma Ata Declaration
stir us to champion such an approach to health. Zimbabwe celebrated success
is in the form of reduced morbidity, infant mortality, maternal mortality
and life expectancy during the years preceding CPHC. We thus urge the
government to fully revisit this approach as we concert our efforts to the
revitalization of the health delivery system. PHC is based on the idea of
"essential health care based on practical, scientifically sound and socially
acceptable methods and technology, made universally accessible to
individuals and families in the community through their full participation
and at a cost that the community and country can afford to maintain. (Alma
Ata Declaration, 1978). Comprehensiveness also appreciates that there are
determinants of health that are outside the health sector and thus provides
an opportunity to mobilize resources and support from other sectors.

PHC makes health delivery more cost effective as there will be a selective
flow of patients from the bottom (Primary Health Centre) upwards the
hierarchy (through secondary and tertiary up to quaternary level).  The IHE
hails PHC for democratization of decision making, Opportunities for agency
presented through PHC helps to make the health system accountable to the
community and at the same time communities can take ownership and this
result in improved efficiency and responsiveness of the system to the needs
of the community.

4.4 Community Participation

Community (popular) participation remains integral to the improvement of
health delivery. The government should strengthen structures that enhance
community participation in health. Community involvement will ensure that
the government takes on board community interests in policy and put in place
measures that the state uses to protect national interests and public goods.
Communities should have an increased role in the governance of resources in
health as a way of reducing marginalization and increase equity in health.
This can be achieved by the participation of communities in the
prioritization of health problems and aspirations as well as resource
distribution. This is however only possible if stable and clear structures
are put in place.

The role of health advisory boards such as Public Health Advisory Board,
Hospital Advisory Boards and Health Centre Committees needs to be appraised
and the roles should be clear. Such structures can if democratized,
meaningfully improve the role of the community. According to T. Bossert et
al. " Influence held by various stakeholders over decision processes could
express local priorities at variance with national priorities and can be a
means of holding the local health staff accountable for higher quality
care." (T. Bossert et al, Oxford Press 2002). The role of the community is
not limited to their participation in governance. Communities can also
contribute locally available resources such as bricks, labour and even
financially – this is very important given the resource constraints being
faced by the health sector. We urge the government to take on board existing
agencies such as those established by the CWGH and other civic groups
working on health and strategically increase their role in the system.

*"…. each community appointed chairmen representing a small group of
households and developed women's organizations, which had an important
political and administrative role within the local health system."
(Johnstone P, McConnan, I, International Health Exchange).*
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