Health care on equal terms? A reflection on the state of Zimbabwe's health care system 40 years
Introduction and Background
At Independence Day in 1980, the late Julius Nyerere, President of Tanzania made the famous remarks to the late founding leader of Zimbabwe, Robert Mugabe, "you have inherited the jewel of Africa, keep it that way". This jewel of Africa included a diverse and strong economy characterised by a booming agricultural industry and a stable macroeconomic environment. However, gross inequalities existed in the ownership and distribution of social and economic goods. The political economy was largely in favour of the white minority and excluded the black majority population. The health sector equally was not spared from such pervasive discriminatory and racially inclined policies that characterised the Smith government. In one review of the White Paper, extensive inequalities and inequities in health were noted. The incidence of tuberculosis was nine times higher in blacks as compared to whites. Rural households which had access to safe water and waste disposal systems were less than ten per cent in total. For every white woman who died whilst giving birth, there were an estimated one hundred and forty-one black women who also succumbed to similar maternal causes. The infant mortality was three times higher in blacks as compared to whites.
These startling health care disparities were also rampant in the distribution of health care resources, such as health insurance, human resources and health care delivery centres. For instance, for every one dollar spent in the rural areas on health services, eight dollars were spent in urban areas ( mostly white residential areas). Furthermore, some districts in rural areas did not have a resident medical doctor at all. The health care system, including its resources, was deliberately framed to serve the white minority population who ironically had better health status. In this line of reasoning, both the tenets of horizontal and vertical equity in health care were fundamentally violated, and health outcomes were mostly shaped by the intersecting identities of class, racism, regionalism/ethnicity, gender and other forms of identity.
The post-colonial administration was therefore presented with an uphill task to radically transform the health sector into an egalitarian system that also conforms to its largely socialist or Marxist ideological orientation. The White paper was thus one of the first and comprehensive policy outlines by the new Zimbabwean government that seemed to create a non-racial public health care system that is predicated on the primary health care approach. It also sought to introduce redistributive changes in health care resources, involve communities in health care planning, limits the privatisation of health care and ensures an equitable health care system. To a very large extent, the post-colonial establishment managed to reverse the racial health care disparities and also rapidly expanded the primary health care infrastructure across Zimbabwe in the first decade of its tenure.
In the period from the year 2000 onwards, the deterioration of the economy, and the ensuing political instability in Zimbabwe had profound consequences on the health care system. In 2008, government health expenditure plummeted from 7% of the national budget in the year 2000 to around 4%. The health sector was also not spared by the massive brain-drain which resulted in experienced health personnel leaving the country for greener pastures because of the deteriorating working conditions. The dwindling resources also negated the strides made in responding to HIV and AIDS in Zimbabwe. In the period of 2008 to 2009, thousands of Zimbabweans lost their lives to a devastating outbreak of cholera. This epidemic was compounded by a deteriorating human rights situation , a collapsed health system in the country and lack of transparency on the deaths from cholera. There was temporary relief after the consummation of the Government of National Unity in 2009 which led to an inclusive government and macroeconomic stability up to 2013. Despite the aforementioned setbacks, the health delivery system in Zimbabwe proved to be resilient, leveraging upon innovative financing mechanisms such as the AIDS levy, a highly skilled workforce and a strong health infrastructure with a great preventative approach built from the primary health care reforms of the early 1980s.
The “new” government led by Emmerson Mnangagwa, which came into power after the ouster of the long-time authoritarian ruler, the late Robert Mugabe is faced with a complex health crisis. The crisis is multifaceted and has recently been worsened by the existential threats posed by the COVID-19 pandemic.
Towards Health Care for All
Financing
Despite the knowledge of disparities in health care insurance and funding since the 80s, the country has dismally failed to adopt a cogent health financing model which is sustainable and ensures universal health coverage. Most Zimbabweans continue to use the out of pocket health care funding model although it has been shown to have a limiting effect on health care utilisation and has thrown millions into poverty. The few insured citizens also face logistical and administrative barriers to access care due to allegations of red tape, mismanagement and a poor legal and policy framework for the health insurance industry. There is therefore need for the Zimbabwean authorities to urgently consider adopting a national health insurance system, that pools funds through among other vehicles taxation and the private sector. This will ensure universal health coverage and elimination of socioeconomic disparities in accessing health care. Political leaders, civil society and development partners need to jointly sponsor a health financing model for Zimbabwe if the right to healthcare is to be realised in Zimbabwe. Zimbabwe has over the years failed to meet the minimum budgetary allocation of fifteen per cent as outlined in the Abuja declaration. This has led to gross underfunding of preventative, curative and rehabilitative health programmes and the generalised state of ruin which the health care system finds itself in.
Health Infrastructure
The health infrastructure and service delivery are grossly in a state of despair. The post-colonial state did not significantly engage in expanding secondary and tertiary health care facilities with the majority of the existing referral hospitals having been built during the colonial era. A majority of those facilities located in mostly urban settings are in a state of despair and can no longer keep up with the rapid urbanisation and growing population. The delivery of essential and emergency services remains grossly crippled by limited financial investment in the health sector with the most essential and emergency drugs coming from donations by development partners. As such, the government needs to engage in a massive infrastructure rehabilitation programme for the health sector, ensuring that more secondary level and specialised tertiary care facilities are built to deal with the rising twin epidemiological burdens of communicable and non-communicable diseases. The Zimbabwean constitution Section 76 provides for the right to healthcare as a fundamental human right. Therefore, the state must progressively ensure the realisation of this right to every citizen.
Medicines and Technology
The macroeconomic instability and the inconsistencies in the monetary policy in Zimbabwe have driven out most pharmaceutical firms out of business. Sadly, this has resulted in over-reliance in the importation of basic medicines, technologies and sundries from outside Zimbabwe. The crippling foreign currency shortages due to reduced export capacity has seen most health facilities experiencing persistent stock-outs of essential medicines and sundries. Recently, Zimbabwe had to rely solely on donations to conduct diagnostic tests for COVID-19. The diagnostic infrastructure for tuberculosis and HIV is mostly supported by external funds from the Global Fund. This has been worsened by lack of deliberate policy interventions that seek to address the declining capacity utilization in the giant pharmaceuticals such as Natpharm, Varichem and CAPS. The drugs and medical sundry supply situation can be best tackled by investing and promoting local drug production. Over-reliance on donations and external support is both short-sighted and unsustainable. The tertiary institutions of higher learning also need to be supported to extensively engage in research and development with the ultimate aim of improving import substitution of basic drugs and health sundries.
Zimbabwe has made good advances in establishing a functional health information management system, the District Health Information System (DHIS). This system provides routine surveillance data on all diseases of national and international concern as outlined in the health regulations. Further, investments need to be focused on utilization and analysis of health data in informing and shaping health policy at institutional, local and national levels. The COVID-19 in its early stages in Zimbabwe exposed the lack of a clear hierarchical information dissemination system by the central government during a health crisis.
Leadership and Governance
Finally, and more importantly, the health sector in Zimbabwe has been grappled with extensive challenges in leadership and governance. Appointments of health sector leaders along with political inclinations without due attention to merit and qualifications has resulted in poor decision making. The PSMAS saga also highlighted how nepotism and corruption facilitated by key central government actors contributed to the demise of the health insurance sector. Oversight management boards such as the Health Services Board have been under persistent scrutiny by the auditor general's office for alleged mismanagement of public funds. The government needs to rethink its approach and consider new public management approaches in the leadership of the health sector in Zimbabwe.
Conclusion
The post-colonial state managed in its first decade to rapidly eliminate racial and socioeconomic health disparities. However, the gains made in these years have been largely reversed by a complex health system crisis which is mostly fostered by perennial underfunding and leadership deficits.
Dr Fortune Nyamande is the Board Chairperson for Zimbabwe Association of Doctors for Human Rights and past president of the Zimbabwe Hospital Doctors Association. He writes in his personal capacity.