<br><br><div class="gmail_quote">From: <b class="gmail_sendername">David Legge</b> <<a href="mailto:D.Legge@latrobe.edu.au">D.Legge@latrobe.edu.au</a>><br><br>
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<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">People's Health Movement Zimbabwe:
Position Paper: June 2008</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">________________________________________________________________________</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU"> </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">1. Socio-economic background</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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.<br> </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU"><span>
</span>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. </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU"><span>
</span>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.<span> <br> </span></span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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.<span> </span>On key indicators, Zimbabwe is
drifting away from the targets for achieving the Millennium Development Goals:</span></font></p>
<p style="margin-left: 36pt;"><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">• Life expectancy
is around 37 years for males and 34 for females, the lowest in the world,
according to <span>WHO</span></span></font></p>
<p style="margin-left: 36pt;"><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">• Primary school
enrolment rates are falling, with girls worse off than boys</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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).</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU"><span>
</span>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. <span>GATS has</span> 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<span> <br> </span></span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU"><span>
</span>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. </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">2 The Issues: Citizens lack access
to quality health care<br></span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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. </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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.<span> </span> </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">3. The role of the State</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">3.1 Health Budget<span>
</span><span> </span></span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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<span> </span>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%<br></span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">3.2 Millennium Development Goal<br></span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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." </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU"><span>
</span>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.<br></span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">4. The CWGH Position<br></span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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 </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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.<span>
</span>Resources should be allocated in response to need. Equity in health care
financing means that individuals (or families) contribute resources to</span></font></p>
<p><span><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">health</span></font></span><font face="Arial"><span style="font-family: Arial;" lang="EN-AU"> on the basis of their
ability to pay, and receive resources for health on the basis of</span></font><span><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU"> their</span></font></span><font face="Arial"><span style="font-family: Arial;" lang="EN-AU"> health need</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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<br></span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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. </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">4.1 State, non state <span>actors</span> cooperation </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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. </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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. </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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) </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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. </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">4.2 Deconcentration of the health
systems</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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.<span> </span>The government should seriously consider the
following key elements of this framework;</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">* 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</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">* Facilitate multi sectoral actions
on health and to work with local non state actors</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">* Introduce the 'New Public
Management'- introduce competition between different public sector
departments</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">* Identifying benchmarks and
indicators to ensure monitoring of the progressive realization of health.</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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. </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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.</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">4.3 Comprehensive PHC </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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. <span>(Alma Ata Declaration, 1978).</span>
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. </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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).<span> </span>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. </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">4.4 Community Participation</span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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. </span></font></p>
<p><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial;" lang="EN-AU">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.<span> </span> </span></font></p>
<p><i><font face="Arial" size="2"><span style="font-size: 10pt; font-family: Arial; font-style: italic;" lang="EN-AU">"…. 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).</span></font></i></p></div>
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