‘Stop blaming vendors for typhoid’
The Daily News on Sunday’s Bridget Mananavire speaks to former Health minister and opposition MDC shadow Health minister Henry Madzorera about healthcare in Zimbabwe which varies from the most basic primary healthcare, supposed to be offered free by the State, to highly specialised, hi-tech health services available in both the public and private sector.
Q: How would you describe the health sector prior, during and post your term as Health minister?
A: In 2008, all the pillars of the healthcare delivery system had effectively collapsed. The first fatal deficiency was the brain drain of health workers as they sought to earn a living both outside the country and within the country. Indeed those who were still working in the public health sector were putting in only partial effort.
Some workers spent most of their time looking for stuff within the hospitals to sell, and items like doors, sinks, and all sorts of voluminous hardware went missing from hospitals.
Hospital medicines migrated to the homes of staff, from where patients could access them at a fee.
Informal charges replaced the usual hospital user fees and healthcare became both too expensive and inaccessible to the majority of citizens. There was a gross shortage of medicines and other products, leading patients to rely on traditional healers for most of their healthcare.
Ambulance services were very skeletal and there was gross dilapidation of infrastructure and equipment.
Most essential services at institutions were not functioning, like elevators at the central hospitals, laundry facilities at virtually all institutions, autoclaves, boilers, mortuaries etc.
There was no linen in the hospitals, and anyone admitted had to bring their own. Each institution had to finance itself entirely through user fees because government was not supporting them.
The independently-run mission hospitals became the backbone of the public health delivery system.
Though they also charged user fees, they were offering a service satisfactory to the clients.
Q: During this time donors stepped in. Was there prudent use of their funds?
A: Impropriety with donor funds, for example the millions of dollars of Global Fund money, were irregularly sequestrated by the central bank on behalf of government. It led to serious delays in implementation of critical donor-funded health programmes notably HIV/Aids, TB and malaria programmes, and subsequently to a long-lasting lack of trust in government as a recipient and manager of donor funds.
By the end of the inclusive government, however, donors had begun to warm up to the idea of government becoming a principal recipient of donor funds. This was a result of demonstrable consistent performance, transparency, and accountability on the part of the inclusive government.
Q: There was an outbreak of communicable diseases as well. What caused this?
A: Communicable diseases, notably cholera, devastated the country from about August 2008. It is regrettable that government delayed seeking international help. This resulted in over 100 000 people contracting cholera, and about 4 288 dying of the disease.
This tragedy was a result of the total collapse of water and sanitation facilities in the cities, and a lack of capacity in the ministry of Health and Child Welfare to respond to the epidemic.
The inclusive government ushered in a new era of trust and hope. Though government would take a long time to recover economically; improved relations with the donor community led to rapid progress in rehabilitation of the health sector.
The health worker retention scheme worked wonders in attracting health workers back into the public health delivery system, and retaining them. We saw hope and morale escalating, and some workers even returning from the Diaspora to come and serve their motherland.
The cholera epidemic was rapidly brought under control through the concerted efforts of rejuvenated health workers, the donor community, the United Nations family and the inclusive government itself.
Q: What did you do to bring the cholera outbreak under control?
A: Extensive rehabilitation of infrastructure and equipment was undertaken, initially using donor funding, and later under the targeted approach funded by treasury.
We witnessed laundry departments, mortuaries, elevators, autoclaves, boilers and a whole host of other essential utilities coming to life. Hundreds of ambulances were procured, and communication was improved by cell phones being placed at every clinic.
Q: It looks like we are sliding backwards towards health disorder?
A: We are seeing a dangerous trend towards the pre-2009 situation. Out of pocket expenditure has shot up once again, with a gross shortage of medicines within the hospitals and clinics.
Patients have to buy from the private sector. It is regrettable that services that we had started taking for granted in the public health delivery sector during the inclusive government era, like ultrasonography, X-rays, and most laboratory tests, are no longer available in public institutions.
Patients have to access these in the private sector at great cost to themselves. Catastrophic health expenditure and impoverishment are on the rise.
Q: And we are grappling with typhoid now?
A: We are witnessing a deterioration of the social determinants of health, notably water and sanitation, poverty and increasing economic desperation.
This is manifesting in an increase in communicable diseases, particularly those transmitted by the oral-faecal route like typhoid. We recorded 181 cases of typhoid and one death in the first three weeks of 2017. This epidemic is out of control.
Unfortunately, instead of government taking ownership of the fundamental causes of the disease and investing in corrective measures, we are shifting the blame to the population, particularly the street vendors.
It is imperative that government deals with the water and sanitation issue, provides decent housing and resuscitate the manufacturing sector to create jobs and deliver the people from vending as a life style.
Q: And doctors have been on strike since Wednesday?
A: The human resource for health situation is deteriorating once again. That post-housemanship doctors should go unemployed for months on end is unprecedented in the history of this country, when in fact the need for more doctors in the system is palpable.
The situation for registered general nurses is more pathetic. In spite of the glaring shortages in the hospitals and overwork of currently employed nurses, hundreds of nurses, trained at great expense to the tax payer, remain unemployed, sometimes for years. This is a bad sign, and needs urgent redress.
Q: Are there any policies or systems that you had implemented that were reversed?
A: Zimbabwe’s Public Health Act came into effect in 1924. We are still governed by this archaic piece of legislation.
The principles of a new Public Health Act were adopted by Cabinet in 2012, and the drafting process had started. It is important to the nation that five years later, the proposed bill becomes law.
At the heart of healthcare delivery is healthcare financing. It is imperative that Zimbabwe gets rid of all user fees paid at point of accessing healthcare.
To that end we started a due diligence exercise in 2010 to define a Universal Health Coverage (UHC) system that would meet the needs of Zimbabweans in terms of quality, accessibility, availability and acceptability with equity, and to work out a suitable progressive pre-payment scheme for universal health coverage financing.
This work was completed in early 2013 but could not be converted into law because of the elections. UHC is the only way to go.
This is still an outstanding agenda item nearly four years later, and we implore the (current Health) minister to expedite the transition to a UHC system and financing mechanism. We, however, commend the minister for convening the very successful “National Research Forum on UHC” in March 2015, which was a natural culmination of all the work done since 2010. It’s now time to turn research into policy. Just a word of caution to the minister: the people do not want Nssa to manage the UHC fund.
Q: Health receives a lot of funding from development partners, is this the reason why government might be under-funding the sector?
A: Development partners are covering a gap which government is failing to cover. In its current state, and in the current state of the economy, government has no capacity to fully fund healthcare in the country.
Over 90 percent of medicines in the public sector are donor-funded, and this is really out of necessity. National Pharmaceutical (Natpharm) has been reduced to a manager of donated products.
I believe government priorities have to change. If government at least complies with the Abuja 15 percent commitment to health, and actually disburses the amounts diligently, it can actually start playing a more meaningful role in healthcare financing.
Q: Do you think the money from donors is enough?
A: Donors are doing a great and commendable job. But their contribution is never intended to cover 100 percent of healthcare expenditure.
The creation of a multi-donor pooled fund was a great innovation and it improved efficiency in utilisation of donor funds.
Q: What is it going to take to rebuild the health sector?
A: The starting point is to comply with the World Health Assembly resolution on universal health coverage, and the minister is responsible.
We must use domestic resources to re-build our health sector. Strong political will is needed, and populist policies that don’t deliver should be shunned.
The primacy of health in the whole economy must be recognised, and appropriate budgetary allocations done.
Q: What would you have done differently?
A: It all comes down to UHC financing. This is an urgent matter and should not be overtaken by the upcoming elections. I would work tirelessly to improve the quantity and quality of our network of service providers.
Q: Do you think Zimbabwe will achieve its goal of universal access to healthcare articulated in the UN Sustainable Development Goals?
A: Yes, Zimbabwe can achieve those goals if we really start owning our health system and stop being cry babies, passing the blame of our failures to others.
No nation has ever achieved UHC using donor funding. We must act promptly on our funding model. Donors come in to fit into our plan. Daily News