/ 6 April 2017

How to fund a failing health system

Zimbabwean doctors went on strike in February for more money and more posts. In 2008
Zimbabwean doctors went on strike in February for more money and more posts. In 2008

For two years, Widna Chiyangwa from Harare, Zimbabwe, suffered in pain. She was in her mid-40s and had four children to feed. But a broken ankle had left her without an income — she could no longer work as an informal trader because she couldn’t walk. Chiyangwa required urgent surgery to fix her ankle, but she couldn’t afford it

Private hospital fees in Harare, Zimbabwe’s capital, were completely out of reach for her. Private healthcare centres would charge between $4000 and $7000 for the x-rays and operation Chiyangwa needed, says Evans Masitara, secretary general of the group  Zimbabwe Association of Doctors for Human Rights. Chiyangwa could also not find help at the country’s public hospitals, where acute drug shortages, ailing infrastructure and ageing or broken equipment threaten even basic healthcare services.

In October it was widely reported in the Zimbabwean media that major referral centres such as United Bulawayo Hospitals suspended surgeries as a result of vital drug stock-outs, including common pain medication.

The cash-strapped government has been struggling to pay health workers on time and in February state doctors went on a three-week strike, paralysing hospitals as they demanded higher allowances and job guarantees for junior doctors.

Nurses joined the strike in a bid to get last year’s bonuses.

At the Beatrice Road Infectious Diseases Hospital in Harare, some health workers complain that they are forced to sleep at work because they can’t afford bus fares. “We are struggling; we are not getting our salaries,” says Winnie Kadzere, one of the staff members at the hospital who went without pay for three months.

Zimbabwe’s health sector needs $1.3-billion annually, Minister of Health David Parirenyatwa reportedly told senators in February. But his department got a paltry $281.9-million in the 2017 budget, only 6.88% of the country’s entire budget of $4.1-billion. The allocation is even less than the 8.27% of the budget that was dedicated to health in the previous year. Recent allocations fall far short of the 15% of national budgets that Zimbabwe and other countries committed to dedicating to health in 2001 as part of the African Union’s Abuja Declaration. 

With the bulk of the health budget ($223-million) going towards salaries, very little is left for equipment and drugs, says Shingi Bopoto, secretary general of the Zimbabwe Medical Doctors Association.

In an effort to bolster the beleaguered health sector, mobile phone users will now have to pay a levy on airtime and mobile data under the theme  “Talk, Surf and Save a Life”. The 5% levy — or five cents for every dollar spent — will be paid into Zimbabwe’s newly created Health Development Fund. 

Government has been forced to look for alternative ways to raise money: as Zimbabwe’s economic woes deepen, its formal tax base has been shrinking. Minister of Finance Patrick Chinamasa admits in his latest budget statement that it is no longer sustainable to rely on these taxpayers.

This new fund is also meant to reduce the Zimbabwean health sector’s dependence on donor funds. Zimbabwe is expecting $177-million from the Global Fund to Fight Aids, Tuberculosis and Malaria in 2017 to buy antiretroviral drugs and medicines, and to train health workers, according to the budget statement.

The Global Fund will contribute $43-million towards malaria control programmes and $11.5-million towards tuberculosis initiatives. Development partners, including the European Union, will donate $48.5-million through the Health Development Fund.

“The shrinking tax base has constrained government’s capacity to invest in the public health delivery system, which is now being augmented with resources from development partners,” Chinamasa says in the budget statement. “The situation is not sustainable as development partners are also experiencing budget constraints, hence, have reduced their support.”

The money raised through the Health Development Fund will be ring-fenced for buying drugs and equipment for public hospitals and clinics, according to Chinamasa.

Although this will not mean free medical care for all Zimbabweans — those who can afford to pay for medicine will still have to do so — it is meant to improve a situation in which the majority of Zimbabweans can’t get healthcare at all. Matters are compounded by the fact that medical practitioners want cash payments upfront as medical schemes either don’t pay or delay their payments.

Need help, will travel
When Chiyangwa could no longer bear the pain of her broken ankle and it became clear she would not get surgery in Harare, she did what many others with ailments do: she travelled. Although the country’s wealthy have turned to medical tourism abroad — India and South Africa are popular destinations for medical procedures and President Robert Mugabe is

known to seek medical treatment in Singapore — she bused about 230km north, to the Karanda Mission Hospital. In November last year, Chiyangwa went into theatre there for the operation she needed for the fracture.

Limping on crutches towards the waiting room, she explained she had come to have the plaster removed.

“I am happy with the treatment here,” says Chiyangwa, who had used all her savings and borrowed from family members to get the $600 she had spent in total. This includes her transport fees, $300 for the operation, $10 per hospital visit and about $20 for x-rays.

This cost about a tenth of what the same procedure would have cost in Zimbabwe’s private healthcare sector. Despite being in a remote area, the mission hospital draws patients from all over the country and has not only become a major referral point, but has also built a reputation for being a “miracle hospital”.

Here the full-time doctors perform over 4000 surgeries a year and medical staff see between 200 and 300 outpatients each day.

As the hospital controls its own budget, it buys its own medicine stocks. The user fees largely sustain the hospital, says Friday Chimukungara, matron of the Karanda facility.

“Whatever we get in fees and charges, we use it for medicines and drugs. There is a bit of funding that comes from the government for infrastructure development, but that is not in any way enough. And of late we haven’t been getting it at all.”

Chimukungara, like many others in the health sector, is concerned about how the new fund will be administered.

“It is a noble idea, but with such issues you always want to make sure that the mechanism is okay.”

New fund comes on the back of previous innovative financing mechanisms
Bopoto, of the Zimbabwe Medical Doctors Association, also calls the new health fund “a noble idea, whichever way funds are raised”, but says the medical community is seeking assurances the money will be used only for what it is intended.

“We are concerned that the funds may not be used properly. And we are also wondering why the Aids levy model, which has been well administered, isn’t being replicated for this purpose instead,” he says.

Zimbabwe’s Aids levy has been widely hailed as a resourceful and innovative approach to fund the fight against Aids. The National Aids Trust Fund, as it is formally known, was started in 2000 and is a 3% tax on the income of the formally employed and most companies. Fifty percent of these funds are dedicated to buying supplies such as antiretroviral drugs, and the rest goes towards treatment, care and prevention.

The Aids levy enabled Zimbabwe to secure generous global funding for its healthcare sector, says economist Reneth Mano.

“Because audited accounts have consistently confirmed that the Aids levy funds are being used for the purpose for which the levy was designed, the Aids levy is probably the only tax on labour for which the taxed workers can identify with the outcome,”

Mano explains. But although official figures on employment in Zimbabwe would suggest 81% of the working-age population was employed, Mano points out that economists and industrialists believe unemployment is 500% higher than the official figures.

The deteriorating economy and jobs cuts therefore leave a shrinking pool from which to collect the Aids levy: Aids levy collections dropped from a high of $38.6-million in 2014 to R32.3-million in 2016.

With tax collection from the formal employment sector predicted to continue falling, Zimbabwe’s telecommunications industry presents a lucrative alternative for raising funds.

But the new tax comes just two years after Zimbabwe’s mobile network operators were slapped with another 5% levy on all airtime purchases for mobile telecoms. They complain this has resulted in falling revenues — and they’re not sure they can take another hit.

Masitara, secretary general of the Zimbabwe Association of Doctors for Human Rights, stresses that he welcomes any efforts to stop the health sector from collapsing, but says it will be a while before the new fund will make any difference.

“Our health system is of great concern. We are also worried about transparency and the pilfering of money collected.”