Community Working Group on Health POSITION PAPER ON BUDGET ALLOCATION FOR THE HEALTH SECTOR FOR 2015 INCORPORATING

Transcription

1 Community Working Group on Health POSITION PAPER ON BUDGET ALLOCATION FOR THE HEALTH SECTOR FOR 2015 INCORPORATING POST BUDGET ANALYSIS FOR 2014

2 KEY BUDGET CONSIDERATIONS 1. HEALTH CARE NOW A RIGHT IN THE NEW CONSTITUTION DEMANDS: a. Urgent realization of equity and quality in the health services delivery b. Expedited revitalization of a recovering health system for universal access and utilization of health services c. Reduction of fiscal funding constraints, in order to achieve the Abuja target of 15% spending on health, and move closer to the WHO s recommended per capita spending on health of USD$60 d. Improved capacity to administer the ever diminishing donor pool of funds, ensuring accountability on all sides in line with the Paris Declaration on Aid Effectiveness e. Building of a national health insurance policy and guidelines which will provide for adequate and sustained pools of pre-paid health insurance tailored for all income levels in the informal and dwindled formal employment sectors; i. Ministry to sort out the gross mis-management of the troubled Premier Medical Aid Society to restore order and the nation s confidence in its oversight and stewardship of all health insurers, its parastatals and other critical health establishments ii. Prudent and transparent revival and finalisation of the national social health insurance, in order to reduce the current high levels of catastrophic health spending by availing pre-paid medical insurance to those who need it most iii. Clearly define the groups that are exempted from user fees to ensure families no longer risk impoverishment through payment for health services and their education and work opportunities are not unduly constrained by illness; while avoiding further impoverishing a system that clearly cannot afford free treatment for all iv. Provide for the requisite financial management software and system that reduces financial losses and pilferage 2. MDGs REPORTING LESS THAN 500 DAYS AWAY a. Unfinished business across the 8 Millennium Development Goals requires concerted efforts and financing to start righting the wrongs and move the country towards favourable health and therefore development indicators b. Early and comprehensive national dialogue on the Post-2015 agenda considerations 3. IMPLEMENTATION OF THE ZIMASSET NATIONAL ECONOMIC BLUEPRINT a. The national approach to addressing the social determinants of health, realizing that without health there is no socio-economic development for the country, and that addressing the key determinants of health will spur the country on a positive growth trajectory b. Development and implementation of a national health financing policy to ensure adequate financing of all health service provision in line with disease profile and population health needs c. Ensuring continual improvements by implementing the results based financing and management, (RBF, RBM), monitoring key health indicators at all levels of health service delivery and regular reporting d. Realization of the increasing burden of non-communicable diseases including cancers on top of the huge burden of communicable and neglected tropical diseases

3 1.0 INTRODUCTION The Community Working Group on Health, (CWGH) applauds Zimbabwe for making provisions for improved health and quality of life in the new constitution by acknowledging that health is a fundamental human right, and that access to quality health care should be universal to all citizens. We further appreciate the opportunity given to the CWGH, other members of the civic community, individuals and institutions to have their voices heard in the constitution making process, and we now demand to see the provisions of this new constitution implemented. The year 2015 marks the 25 th year after the 1990 United Nations Millennium Declaration, which ushered in the monitoring of 8 Millennium Development Goals, (MDGs), as a basic and minimum set of requirements for human development which were to be measured within and across nations as from the year At the time of writing this report the world stands at less than 500 days before the watershed reporting of these MDGs. Zimbabwe has managed to achieve less than half of these developmental milestones, and definitely not fared impressively on the 3 health related MDGs. In addition the remaining 5, while not directly health related, represent the key determinants of health, and their achievement would have meant that high quality health is enjoyed by the majority of Zimbabweans for the development of the nation. 2.0 HISTORY OF HEALTH MEASUREMENT AT GLOBAL AND LOCAL LEVELS A number of global, regional and local milestones have been researched, deliberated and agreed on, since the landmark September 1978 Alma Ata Declaration that ushered in the Primary Health Care Philosophy and Approach to health service delivery. This was adopted at Independence in 1980, and has been the cornerstone of health service delivery in Zimbabwe. Thereafter followed the Health for All by the Year 2000, the Abuja Declaration on ensuring at least 15% of the Government spending is allocated to health, the Millennium Development Goals (MDGs), the Paris Declaration on Aid Effectiveness... among others that the country acceded to. All these are arrived at after assessing population health status, defining the gaps in service provision and defining the required interventions to improve quality of health, reduce premature and avoidable deaths, and hence define a set of indicators to track progress or lack of it. Our concern remains the fact that these agreements represent minimum requirements for national health and development, and while it is important that the country has acceded, ratified and agreed to their implementation and monitoring, there is need for scrutiny on why achievement of the targets has been minimal. Furthermore, major considerations and decisions must now be made before any new commitments are made on what benefits accrue to the nation s continued participation in these processes in the face of continued failures to achieve the set milestones.

4 2.1 How Has Zimbabwe fared in key Health and Development Goals? As we report the country s progress or lack of it on the MDGs, the country must take stock on the few achievements and learn the best practices; while looking at the failures, which in the 3 health specific goals, MDG 3, 4 and 6 all mean loss of lives from avoidable diseases, (HIV/AIDS, malaria, tuberculosis, other communicable diseases, and conditions, (pregnancy, malnutrition, infancy). The question earlier raised of what value the country derives from ratifying these international treaties on health, while continually reneging on their implementation and hence delivery of the proven effective interventions? This means that the population has continually been denied the opportunity to realize optimal health, and, by implication compromised their contribution to individual and national development. The key point here is that these targets are the very basic or minimal developmental milestones, and by achieving them, the Government would have realised its own goal of the highest quality health for all citizens, however, the current state of affairs leaves this as just another mantra. We are far from having a healthy population, and this is despite health, and health care provision being a constitutional right for all Zimbabweans. The key health indicators for the generality of the Zimbabwean population have improved little since the time of drafting of the White Paper on Health in In fact the best indicators were reported just before the advent of AIDS in the late 1980s into the mid-1990s and thereafter there was a decline. These standardized measures which allow comparisons within the country over time periods and across borders provide an objective monitoring framework of health, health status and national development. In the current thrust, a number of health access and health service coverage indicators, (maternal-, peri-natal-, newborn- and child-morbidity and mortalities; general and reproductive health, nutrition, MDGs, communicable and non-communicable diseases, neglected tropical diseases and conditions such as injuries and mental health) and the recommended priority interventions related to, and indicators for financial risk protection; all demand close considerations and monitoring if the health care provision in the new Constitution is to be realized. The table below shows the increases rather than decline in both infant and crude deaths rates over time. Note that these are measured during population surveys and therefore figures may not be available on annual basis. Table of Mortality Trends for Infants and the General Population Year Infant Mortality Rate /1000 Crude Deaths Rate / /6 60 (Demographic & Health Survey) /11 80 (Demographic & Health Survey) (Population Census) 10.2 (Population Census) ?? - No data available, ie non- survey years? How will we fare at MDG reporting?

5 Deaths per 100,000 live births Trends of Maternal Mortality Ratios / Live Births; 1990 to MDG target WHO/UNICEF/UNFPA/World Bank, 2012 DHS 2.2 Realizing Quality Health and Equity The Role of the CWGH The CWGH acknowledges that government cannot accomplish its goal and national vision of delivering the highest possible level of health and quality of life for all citizens alone, but requires the combined efforts of individuals, communities, organizations and the government. It is this vision which guides our organizational direction; hence our annual contribution and submission of this position paper. The principle of universality calls for measures that ensure that the entire population has access to health interventions and services, while the principle of equity calls for measures to close the avoidable inequalities in health and in access to resources for health, allocated in relation to health need, including actions on the social determinants of health. As CWGH we maintain the importance of ensuring equitable delivery of an agreed benefit package and call for equity and efficiency in the allocation of resources, transparency, accountability and social participation in the management and use of resources for health. To this end we applaud the MOHCC in embracing and implementing the results based financing model, (RBF) in 18 districts, and the government s results based management, (RBM) in the remaining 42 districts. Both frameworks require community involvement, accountability and governance mechanisms in health and contribute greatly towards improved access and utilization of health services by the population by ensuring availability and efficient use of financial resources at the lowest levels of the system.

6 The CWGH was born in 1998, to lead and give visibility to community processes in health. We fully embrace the concept of equity and universal health coverage, (UHC) in Zimbabwe in line with the primary health care philosophy. To this end the CWGH has worked closely with the MOHCC, supporting the implementation of its National Health Strategy, : Equity and Quality in Health a People s Right. The Strategy, now extended to 2015, raises universality, equity and quality as central principles. As the Ministry embraces the UHC and equity monitoring through its national health information system, we are optimistic that the importance of multisectoral influences on health should be acknowledged in order that there is a clear link between monitoring of progress towards UHC with monitoring the social and environmental determinants of health and sustainable development. This is in line with the mandate and context of the post-2015 development agenda, on the global arena and the Zimbabwe Agenda for Sustainable Socio-economic Transformation, (ZimAsset) on the local arena. 2.3 Health Financing Now and Beyond the MDGs This paper, therefore advocates for the Government of Zimbabwe to honour its commitments to ensure adequate health dollars as from the 2015 national budget onwards, as well as craft its own set of developmental goals that strive for sustainable well being for all, (wealth, gender, equity, education, nutrition, environment, security, etc), while health specific goals should aim to maximize healthy lives at all stages of life with clear strategies of contribution by other sectors to health, in line with provisions of its Constitution. It is therefore imperative that as the country braces for the MDG reporting, a deliberate program be developed to ensure the unfinished MDGs business is taken care of, while at the core of what will be agreed upon in formulating the Post MDGs agenda, must be Universal Health Coverage, by a comprehensive package that is responsive to the national disease profile including the non-communicable diseases, cancers and injuries, (NCCIs) ORGANIZATION OF THE PUBLIC HEALTH DELIVERY SYSTEM The country has 8 rural provinces, but 7 provincial hospitals, (Matabeleland still without), 7 central hospitals and 62 district hospitals, and a total of 1551 health institutions. Specialists are available only at central hospitals and few provincial hospitals, with none at the district level. In addition there is a distinct rural urban difference in quality and availability of services, which is in direct contrast with both the principal of quality and equity in health that Ministry of Health and Child Care strives to practice. Since time immemorial, health care professionals have shunned the rural and lower levels of health care delivery, and this has translated into adverse health outcomes and unfavourable indicators on population health status from compromised access and utilization of the health care services. The Zimbabwean health care delivery system must therefore quickly move to embrace the World Health Organization s six building blocks of an effective system in order to reverse most of these adverse health indicators.

7 The Review Commission on Health in 1999 recommended the creation of a Health Service Commission for Health Workers in order to improve their number, availability and working conditions. This became known in 2005 as the Health Service Board, (HSB). This Board must convince Government of the unique nature of health care workers, and also ensure they are fully capacitated and closely monitored to deliver the health mandate to an ailing population. The HSB s impact is still to be demonstrated in ensuring the highly skilled Zimbabwean health care workers are availed to work in their own country, and contribute to the reversal of the high morbidity and mortality currently prevailing. The recent statistics show a worsening rather than improvement of some key health indicators that directly relate to population health and avoidance of preventable deaths. 4.0 CURRENT HEALTH SITUATION ANALYSIS a. Socio-economic Situation The economic situation has continued to deteriorate, characterized by deindustrialization, company closures and reduced local manufacturing, (CZI 2014). According to the 2010/11 Demographic and Health Survey, more than 70% of the productive age groups are engaged in informal economic activities, with limited sustainability of earning due to the erratic nature of the informal sector in Zimbabwe, compounded by lack of financing and capacitation. This situation not only results in deepening poverty through job insecurity and losses, it also results in dumping of substandard foreign foodstuffs, drugs and medical supplies, as quality of these cannot be guaranteed as could be done through the local production chain. This situation has also contracted the number of medically insured people, thus exposing an even greater proportion of the population to out of pocket and catastrophic expenditure on health. The socio-economic situation exposes the population to diseases and conditions associated with poor incomes, overcrowding and poor service provision. These include stress, under-nutrition, STIs, HIV/AIDS, diarrhoea, neglected tropical diseases, cancers, and injuries. The UN Human Development Report of 2012 says 52% of Zimbabweans live below the poverty datum line. According to the National Health Profiles of the Ministry of Health and Child Care and Zimstat publications, there have been increases in both the crude and disease specific mortality rates across all ages, as confirmed by the subdued life expectancy of 43 years. b. Environment and Living Conditions Most of the 20 urban locales including the capital city, Harare have since the unprecedented cholera outbreak of 2008/9 continued to have poor sanitation, overcrowding (poor living conditions), erratic potable water supplies of questionable quality; and these conditions continue to fuel the known killer communicable infections which used to be rare in the country. In addition, unregulated urbanization has resulted in overloading of the old poorly maintained public health infrastructure and overloaded underfunded systems; roads, refuse collection, sewerage. The National Shelter Indicator Survey has indicated up to 20% of households in Harare are living in backyard, illegal sub-standard structures. The sewerage and water

8 reticulation systems remain unimproved despite high deaths and debility from diarrhoea and related diseases. i. TB also related to poor housing and poverty persists in the population and now includes the resistant, multi-drug resistant type ii. Work related injuries due to poor health and safety provisions at work. iii. Road traffic accidents and catastrophes due to poor road engineering, lack of a national transport system, the bulk goods are moved on roads instead of railway, poor regulation of drivers including young boys in charge of Combis when compared to the older mature United or Zupco drivers. c. Demography The 2012 Population Census gives the annual average inter-censal growth rate as 1.1%, and the total population as 12.3 million. A number of factors have affected the population growth rate from the 3% and above in the past decades; the effects of a high HIV sero-prevalence, poor health service delivery causing high maternal, infant and child mortality, as well as high rates of outward migration to other countries. There has also been high uptake of family planning, resulting in planed children well spaced. Overall, the country has a young population, and the country should be able to harness the Demographic Dividend, which other countries do not enjoy due to having an aged population; but only after addressing the negative demographic and epidemiological features. d. Epidemiology The country has battled the HIV/AIDS pandemic and registered successes of reduction in both incidence and prevalence. However it is important to note that it has not yet stopped new infections nor stopped AIDS deaths. ART coverage is high, but not universal, and TB prevalence mirrors that of HIV; meanwhile the supply of basic drugs and health services remains erratic such that some patients still complicate and/or die from preventable diseases. Neglected tropical diseases, (bilharzias, intestinal worms, elephantiasis, leprosy, sleeping sickness and blinding trachoma), that have in the past not received much attention have become highly prevalent. The above mentioned communicable disease burden is compounded by an equally huge non-communicable burden of nutritional insufficiency, cancers, hypertension, heart disease, diabetes mellitus, injuries, among other diseases and conditions. Most of these are fuelled by determinants that are outside the health service Ministry and therefore require concerted efforts by all sectors to address these causes of ill health. 5.0 FINANCING FOR HEALTH IN ZIMBABWE 5.1 Proportionate Spending on Health The major source of funding for health in Zimbabwe is the Government. This includes provision of the infrastructure that caters for preventive, promotive, curative and rehabilitative health service provision to above 70% of the population. This is complemented by the local authorities, church based/mission hospitals, private for profit sector and the non-governmental organizations in health. Government provides

9 the health service delivery infrastructure, medicines, health worker salaries and training of the health workers. Over the years financing for health has been limited and this has limited availability of adequate medical supplies, operational budgets including for maintenance, translating to poor service delivery and therefore adverse health indicators. 5.2 Fiscal Disbursements to Health Ministry the 2014 Post Budget Analysis In addition to the gross inadequacy of the allocated funds, ranging from 2.4% to a highest of 9.6% in 2010, (much less than the agreed 15% at Abuja, 2000), the disbursements have over the years been erratic and seriously compromised effective planning and implementation of programs, and also severely limited availability of funds at the local or implementation level. The 2013 budget allocation was 9.8% of total Government allocation, missing the Abuja Target by 5.2%. This translated to per capita allocation of $29.30, against the WHO recommendation of $60, recently revised from $34 to cater for the burden of cancers and other non-communicable diseases. The 2013 budget allocation responded to 52.6% of Ministry s requirements, while this dropped to 47% in the 2014 budget allocation which has left Ministry with an unfunded gap of 53%: Of the requested USD$ , based on requirements, MOHCC was allocated only 47%, that is, USD$ , inclusive of salaries, leaving an unfunded gap of $ As at 30 June, 37.8% of the allocated budget had been received, most of this went to cover salaries and previous year s debts, (utilities, Oxygen, Blood, suppliers) Only 5 out of 16 programs had received some sort of funding, and this severely compromises service provision. 5.3 Complementary Funding for Health A number of major donors have supported Ministry, including the Global Fund on Aids, TB and Malaria, and recently the pooled funding mechanism of the Health Transition Fund; supporting maternal and child health interventions. However these funds are disease specific and inadequate especially in the face of the increasing challenges of the high communicable diseases burden imposed by the persisting adverse environment of poor water sanitation and hygiene, the emerging pandemic of non-communicable diseases including cancers and injuries. These are not all

10 catered for under the current financing arrangements mentioned above, and their increased prevalence demand exploration of additional financing mechanisms, seeing that Government and major funders continue to leave them out. 5.4 Innovative Domestic Health Financing Mechanisms The CWGH acknowledges the fact that there are fiscal and social limits to any new taxes or increases in income taxes. However there is local support and many international examples of financing for health from earmarking of existing taxes on areas of consumption that have negative consequences for health, as well as from the formal and informal sector that have higher earnings, such as through tax on non-basic goods. The principle for institutional management of the earmarked funds could therefore draw on experiences from the Aids levy, and other forms of fund management. We therefore recognize the work done by the Public Health Advisory Board on domestic health financing, to complement other work on health financing implemented or underway, and recommend that the fiscal space for tax options should be assessed as part of the work in order to set up systems to expand fiscal space. It is important that both Ministry of Health and Government develops systems and capacities that aim at reducing fragmentation in health financing, avoid direct payments, address social determinants of health, and ensure accountability in all aspects from the lowest levels of community. We therefore implore Government to seriously look at the various options that have been put forward for innovative domestic health financing over and above the national Aids Trust Fund, as a way of ensuring that all key causes of ill health and deaths in the country are adequately addressed, even as the Government strengthens its revenue base. 6.0 RECOMMENDATIONS BY THE CWGH TO THE 2015 BUDGET: Health is central to all development in the country, and at this present moment restoration of health is a key enabler of the effective implementation of the National Economic Reform, ZimAsset. The Community working Group on Health therefore recommends the following: 6.1 Government to improve the global budget allocation given to the MOHCC the CWGH would like to see a situation whereby the government of Zimbabwe fulfils its obligation of allocating at least 15% of its budget to health in line with the Abuja Declaration on health spending; and quickly moving to the WHO s recommended per capita spending on health of USD$60

11 6.2 Government to provide a full health worker establishment which is responsive to the population health needs, the disease burden and distribution of its health service institutions, and in line with the Constitutional provision of health care as a right 6.3 Basic public health infrastructures in urban, informal, resettlement and rural areas need improvement, and the new resettlement area deficits in public health measures (water etc) need to be addressed 6.4 In turn we expect the Ministry of Health to develop and demonstrate its ability monitor performance by implementing both the performance based financing and results based management programmes; ensuring that firm decisions are made on non-performers In line with ZimAsset, implement the results based frameworks RBF/RBM system wide, for improved local level health resourcing and planning 6.5 The Health Service Board must incentivise key personnel to work in districts and avail specialists at Provincial and City Health levels, and in addition ensure the provision of quality services through effective management and governance structures at all levels; that is, hospital management boards, for district, provincial, city health institutions, accountability mechanisms for the respective health directorates, and health centre committees at all health facilities. 6.6 Ensure community accountability mechanisms through the strengthening of health governance at all levels of the health delivery system by putting in place community involvement mechanisms at all levels of health care provision, capacitating and monitoring them to perform 6.7 Finalize the legality of Health Centre Committees and work on the requisite legislation required to empower all the other accountability and governance structures Provide the linkages between medical directorates and other institutional governance mechanisms, such as hospital management boards and Ministry Headquarters 6.8 Institute financial accountability mechanisms, including improving the ability of MOHCC to adequately account for all players in health Support the finalization and implementation of the national health financing policy Improve on health financing literacy and financial jurisprudence across all levels of the health delivery system Provision of accounting software to all levels that handle funds to reduce leakages Build public trust, communication and a political culture of transparency and intolerance to corruption in the management of funds for health

12 6.8.5 A significantly larger share of the budget should go to the district level Assess the feasibility and projections of various areas of domestic health financing through earmarked taxation that is progressive, linked to sectors that are expected to grow substantially and to key areas of population health 6.9 Monitor progress in addressing Equity and Universal Health Coverage 6.10 Convene a national dialogue on the adoption and implementation of global, regional and local declarations, including early and comprehensive dialogue on the post-2015 agenda 6.11 Improve domestic sources of health financing in view of continued fiscal under funding for health and the shrinking donor pool of funding for health Revitalize the drive for a National/Social Health Insurance in order to minimize catastrophic spending on health through provision of a prepayment mechanism for both informally and formally employed citizens Strengthen accountability by all local health insurance companies to reverse the current drive to impoverish the health of prepaid people, (the PSMAS situation) Provide funding to address key non-communicable diseases including the commonest cancers and injuries

13 Sources/References 1. The Abuja Declaration 2. Health Systems Strengthening Building Blocks, World Health Organization 3. Deliberations African Health Economics Conference, Nairobi, March CWGH Pre-budget position papers 2004, 2005, 2010, The Constitution of Zimbabwe 6. UN MDGS 7. Government of Zimbabwe, BLUE BOOK 8. National Health Accounts 2005, Public Health Advisory Board deliberations and actions 10. The Technical Working Group on Advancing Equity in Universal Health Coverage in Zimbabwe deliberations, (MOHCC, TARSC) 11. Selected Zimstat publications, PICES Survey 12. Budget Analysis, 2013, 2014; MOHCC Finance Directorate 13. World Bank WHO Decision Paper on the Post 2015 Agenda 14. Rusike I. and E Sharara (2014) Formulating new goals for global health, and proposing new governance for global health (GO4HEALTH) Community consultations on proposals for a new set of indicators on universal health coverage, CWGH with CEHURD and (GO4HEALTH) For further details please contact: Itai Rusike (Mr) The Executive Director Community Working Group on Health (CWGH) 114 McChlery Avenue Eastlea Harare Zimbabwe Tel: Cell: itai@cwgh.co.zw Skype: itairusike Facebook.com/CWGH