*Mrs Jongwe a sixty nine year old grandmother was wheeled into the emergency department, unconscious around eight in the evening. The doctor attending to her made a working diagnosis of cerebrovascular accident secondary to poorly controlled hypertension and recommended rehabilitation.
She had been found collapsed on the kitchen floor around midday by her granddaughter who had left early in the morning to do laundry at a borehole five kilometres from their homestead. The neighbors heard the granddaughter scream and rushed to see what was happening, then quickly looked for a wheelbarrow to take Mrs Jongwe to the nearest rural healthcare center about ten kilometres from their village. Upon arrival the nurse called for the only ambulance from the district hospital 100 kilometres away covering the entire district of a population of more than 100 000.
Mrs Jongwe was diagnosed of hypertension two years prior but had an irregular supply of her treatment for the past year. Her notebook showed that she rarely missed her scheduled reviews and medication was prescribed but often indicated to be out of stock. She relied on subsistence farming and the occasional pay out from an international non-governmental organization working in the community. She was responsible for two of her grandchildren whose mother had remarried and relocated but could not financially support the family. The older granddaughter was fourteen years of age but had stopped going to school because of lack of funds and her young brother ,a nine-year-old was still in school. The neighbours were worried about the implications of the stroke on the welfare of the family.
Section 76, sub-section 1 to 2 of the Zimbabwean constitution states that:
“(1) Every citizen and permanent resident of Zimbabwe has the right to have access to basic health-care services, including reproductive health.
(2) Every person living with a chronic illness has the right to have access to basic healthcare and services for the illness.
Zimbabwe, a country once regarded as the bread basket of African has been having economic challenges for the past two decades with a brief recovery from 2009 to 2018 after introduction of the multicurrency system. The long term ruler Robert Mugabe was forced to step down in November 2017 which eventually led to general elections in July 2018 and formation of the current government. However the economy seems to be worsening with the International Monetary Fund estimating that the year over year inflation reached an all-time high of 300 percent in August 2019.
The health sector has been negatively affected by the current economic crisis in the country resulting in most health professionals being incapacitated to even report for work. In a recent statement by the Zimbabwe Medical Association, they acknowledged that institutions were poorly resourced and doctors barely remunerated sufficiently. Public health care centers face constant stock outs of essential drugs and struggle to service equipment. The most affected being non-communicable diseases since these are not covered by most donor funded vertical disease control programs.
The health sector is primarily funded from government collected revenue through taxation. In 2019 budget, health was allocated about 7.1% ,which is almost half of the recommended 15% agreed at the Abuja declaration and 80% of the allocated funds are spent on salaries of health workers.¹ The government also collects AIDS levy which is 3% of income and was introduced in 2000 due to the AIDS pandemic. The country gets significant donor funding for specific disease control programs like HIV, TB and malaria and for staff retention.
The country currently has no national insurance program but there are private health insurance providers with 10% of the population having medical aid cover.² Most of the covered population are in the urban communities. Primary rural health care centers have no consultation fees but often patients are expected to buy prescribed medication due to shortages. The majority of the population has to pay out of pocket in a country with a poverty prevalence of 70.5% with the rural areas most affected with a prevalence of 86.0%.3 There is also concern about how the current structural reforms to reduce government spending may be worsening the already dire situation.
There is need for a feasible and sustainable framework for funding Zimbabwe’s healthcare system. The government has been considering measures that will include contributions from the informal sector which may not be contributing to income tax. In October 2018 the Minister of finance introduced a 2% intermediated money transfer tax (IMTT) on electronic money transfers to improve revenue for government capital and social projects. Members of parliament have been lobbying for introduction of sin taxes on alcohol and cigarettes to finance health.
In May this year the Minister of health reviewed that plans are underway to introduce a national health insurance scheme by January 2020. National health insurance may increase the proportion of insured citizens. They can integrate community based insurance into the national health insurance plan. Already there are some communities with community fund pooling programs for funeral cover, business projects and even personal use. These can serve as models to learn from for acceptability and feasibility.
Rwanda has more than 80% of its population covered by the community based insurance program with a separate program for civil servants and the military. 4
The community based insurance program greatly assisted in covering the rural communities. The program was successful because of community participation and political will from the Rwandan government. Zimbabwe can learn from Rwanda however there are concerns about how the program will be financed.
Setting up a National Health Insurance scheme in Zimbabwe might not be straightforward. The country still has a huge external and domestic debt which in 2017 was estimated to be 40% and 32% of GDP respectively 5 and rising inflation with more than half of the population (8.5 million Zimbabweans) estimated by UN to be food insecure . The expected contribution might be unaffordable for the rural poor. ZImbabwe is still considered a fragile situation so is expected to continue needing donor funding and humanitarian aid especially after cyclone idai and the current severe drought though the government has to come up with strategies to reduce reliance on external funding particularly for developing and strengthening horizontal health systems .
An equitable approach to health funding is essential for Zimbabwe to realise Universal Health Coverage and ensure that people from rural communities like Mrs Jongwe enjoy their right to at least basic healthcare minimizing risk of catastrophic expenditure. The government has to increase its allocation for health to at least 15% of the national budget and explore other sources of health specific taxes, to supplement the proposed national health insurance pool, with an extensive community base to bridge the gap for the uninsured 90%.
Most importantly political and economic stability are necessary for improved financing of the health sector in Zimbabwe. These will help in nurturing an environment that promotes good governance and stewardship for efficient use and distribution of the available and pooled resources.
*Not her real name
- The National Health Strategy for Zimbabwe 2016 to 2020
- Mugwagwa JT, Chinyadza JK, Banda G. Private Sector Participation in Health Care in Zimbabwe: What’s the Value-Added?. J Healthc Commun. 2017, 2:2. doi: 10.4172/2472-1654.100050
- Zimbabwe National Statistics Agency Poverty Report 2017
- Rwanda community based insurance policy rbc.gov.rw
- ZIMBABWE STAFF-MONITORED PROGRAM—PRESS RELEASE AND STAFF REPORT IMF Country Report No. 19/144