Key Sector Priorities and Considerations

• To achieve Universal Health Coverage (UHC), actions to address the social determinants of health must be implemented. The social determinants of health (SDH) are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems. Numerous studies suggest that SDH account for between 30- 55% of health outcomes. Addressing these factors must be prioritized.
• Increasing public health expenditure in tandem with the increased population and growing disease burden is an urgent imperative. Raising domestic public funds is essential for UHC. No country has made significant progress toward UHC without increasing reliance on public revenues. Sustainable progress toward UHC requires that a country’s health financing system consistently generate sufficient, largely domestic resources. Empirical evidence has shown that government financing is the most efficient and equitable way to fund health coverage.
• Primary health care is the frontline of Zimbabwe’s health system. Primary health care is usually the first point of contact people have with their health care system, and ideally should provide comprehensive, affordable, community-based care throughout life. A strong, well-funded and accessible primary health system keeps people healthier and out of hospital by supporting them to manage their health issues, including chronic conditions, in the community. This reduces Zimbabweans’ reliance on costly acute care, such as specialists, emergency department or other hospital services. Its therefore vital to specifically budget for primary health care. There is a need for the government to especially increase investment in the PHC sector since it is an essential component in improving UHC and overall health outcomes. The district and community health systems are the foundation of the national primary health care
• A strong health workforce is the cornerstone of every health system and is essential to ensuring UHC and the attainment of SDGs. The health worker establishment needs to be reviewed in line with the population growth, growing disease burden, and health emergencies. There is a need to ensure the sustainability and competitiveness of the health workforce, particularly to secure adequate numbers of health professionals in remote areas as well as improving working conditions, remuneration, and career prospects, especially for nurses, to support retention. Appropriate incentives must be designed to ensure equitable distribution across urban and rural areas ensuring access to underserved populations. Moreover, it is important to absorb Village Health Workers (VHWs) into the government payroll system.
• Strengthening Manufacturing Capacity to Improve Access to Quality-Assured Essential Medicines. Progress towards UHC is dependent on the availability of quality-assured essential medicines. However, ensuring a sustainable supply of these medicines can support pharmaceutical manufacturers to achieve compliance with international quality standards such as WHO PQ (WHO, 2017) can help to address issues related to the supply of essential medicines.

• Limited access to sexual and reproductive health services implies that most women (especially in rural areas) cannot choose if and when to have children. This can increase women’s careload and exacerbate existing inequalities in caregiving. The National Budget must therefore improve access to sexual and reproductive health services, especially for adolescents through providing funding for sexual and reproductive health education, counselling, contraceptive provision, community mobilization, and female empowerment strategies. Strengthening sex education is a primary strategy for achieving improved adolescent sexual health outcomes through improving sexual health literacy, and building awareness, confidence, and skills.
• There is a need to invest more in addressing mental health issues in Zimbabwe. Inadequate financing for mental health is the biggest limitation, adversely affecting efforts to expand Zimbabwe’s mental health workforce and capacity. The country must prioritise the implementation of the Framework to Implement the Comprehensive Mental Health Action Plan in the WHO African Region through increasing public expenditure on relevant services, and mobilising resources from
• Enhancing the health service delivery through leveraging digital economy platforms such as telemedicine is also critical as it helps to reduce costs and enhance efficiencies. In many countries, the use of electronic health records, telemedicine, and digital platforms has improved efficiency and patient outcomes. This technological integration could serve as a valuable lesson for Zimbabwe in enhancing its healthcare

1.0       Introduction

Improving the health and quality of citizens is critical for Universal Health Coverage (UHC) and sustainable development. The strength of a nation lies in the health of its citizens. Being healthier makes one wealthier and more productive. Health saves and improves lives. The health sector is a productive sector that builds human capital, reduces poverty and inequity, safeguards health security from pandemics, improves workforce productivity and provides employment. Prioritizing health is therefore a catalyst for a broader virtuous cycle of sustained and inclusive growth.

While the country has made some progress in terms of ensuring healthy lives and promote well-being for all at all ages, challenges still remain. These include: inadequate budgetary allocation and gross public under-investments, depleted and demotivated healthcare workforce, high prevalence of communicable and non-communicable diseases, growing incidence of mental health illnesses/disorders, inadequate and poor maintenance of healthcare infrastructure and ill-equipped hospitals, prohibitive cost of emergency and specialist services is prohibitive and there is a lack of decentralisation of such services. The poor continue to bear the highest burden of diseases and experience high levels of financially crippling healthcare costs. Many Zimbabweans still lack access to basic primary healthcare services like reproductive, maternal, antenatal care, facility-based childbirth, contraception, and new- born and child nutrition. The erratic growth rate and high levels of informality have contributed to the weak domestic resource mobilization capacity. This has adversely affected public investments in critical productivity-enhancing and poverty-reducing sectors of the economy such health, education, social protection and infrastructure. Consequently, the country continues to experience high levels of poverty and inequality.

Increasing public health expenditure in tandem with the increased population and growing disease burden is an urgent imperative. Raising domestic public funds is essential for UHC. No country has made significant progress toward UHC without increasing reliance on public revenues. Sustainable progress toward UHC requires that a country’s health financing system consistently generate sufficient, largely domestic resources. Empirical evidence has shown that government financing is the most efficient and equitable way to fund health coverage. Moreover, addressing the key determinants of health will significantly improve the performance of the health sector. This should entail: ensuring that the economy is growing sustainably; expanding key infrastructural facilities; improving access to potable clean water and sanitation; ensuring environmental sustainability in the use of natural resources; improving transparency and accountability in the use of public funds and other national resources. These factors and key determinants have to be addressed holistically and comprehensively in order to improve the conditions of health and development.

The Community Working Group on Health (CWGH) is a network of community/civic based organisations whose aim is to collectively enhance community participation in health in the country. The formulation of the National Budget is an area that requires greater participation of the community. Community participation in health matters and budget formulation gives the citizens an opportunity for their voices to be incorporated in the National Budget as provided for in the Constitution and the Public Finance Management Act. The CWGH undertook consultations in the 10 provinces of the country where the CWGH is operational and the sample of respondents included CWGH national members, CWGH District Health Forums, Health Centre Committee (HCC) members, Health Literacy Facilitators and Community Health Monitors members with a balance between men, women and youth. This submission captures the main issues that came from these stakeholder consultations across the country on the state of health, its social determinants and what must be done to address the challenges plaguing the health care system. This position paper is therefore a synthesis of the views of the citizens towards the National Budget.

2.0       Socio-Economic Context

Economic slow-down: Economic growth is expected to be much more subdued than initially projected. The Ministry of Finance, Economic Development and Investment Promotion, in the 2024 Mid-term Budget and Economic Review revised the growth projection to 2% from an initial projection of 3.5% contained in the 2024 National Budget Statement. This is a slowdown from the estimated growth rate of 5.5% in 2023; 6.5% in 2022; and 7.8% in 2021 (see Table 1). The African Development Bank also expects the Zimbabwean economy to grow by 2% in 2024, 1.6 percentage points lower than its previous forecast, owing to a combination of the drought, weak commodity prices and high public indebtedness. Real GDP growth in 2023 was mainly driven by expansion of agriculture output, favourable commodity prices in the mining sector and growth in the tourism and services sectors. The weakening economy affects aggregate demand across all sectors of the economy. Economic growth in the country over the past years has neither been employment-intensive nor poverty-reducing. Economic growth is vital to sustaining financing of critical sectors such as infrastructure, health, health, social protection, and water and sanitation. Erratic economic growth has contributed to limited domestic resources being channeled to critical sectors of the economy. Slow economic growth often leads to a decrease in job creation and a rise in unemployment rates. Growing economies are associated with longer and healthier lives. Economic growth is vital to sustaining financing of critical sector such as health, social protection, and water and sanitation

Table 1: Selected Macroeconomic Indicators

Source: Ministry of Finance; IMF World Economic Outlook database; World Bank World Development Indicators; UNCTAD database.

Weakening ZiG: The period following the introduction of the ZiG was marked by relative macroeconomic stability as evidenced by the significant fall in the inflation figures. However, in August there was an increase in inflation as a result of the depreciation of the ZiG on the parallel market. The August 2024 USD annual inflation rate was 3.7% from 3.6% in July and the monthly USD inflation rate was 0.2% from -0.1% in July; the August 2024 ZiG monthly inflation rate was 1.4% from -0.1% in July; the August 2024 monthly blended/weighted inflation rate was 0.4% from -0.1% in July. The country has a long history of chronic high inflation. The main drivers of inflation in Zimbabwe are money supply growth, the black- market premium (exchange rate developments), and energy and fuel price developments.

Challenging doing business environment: The doing business environment remains very challenging. Competitiveness has been seriously eroded by the high cost of doing business. According to the 2023 CZI Manufacturing Sector Survey, capacity utilisation in Zimbabwe’s manufacturing sector fell by 2.9%, to 53.2% in 2023 from 56.1% in 2022 and 56.3% in 2021. Furthermore, the manufacturing sector’s contribution to GDP fell to 9% in 2023 from 14.8% in 2018. According to UNCTAD, FDI inflows into Zimbabwe increased from US$250 million in 2021 to US$395 million in 2022 and US$588 million in 2023. FDI inflows were US$5.2 billion in South Africa; US$2.5 billion in Mozambique; US$2.3 billion in Namibia; US$208 million in Malawi; US$198 million in Botswana; and US$108 million in Zambia. The erratic power supply situation threatens the viability of the sector with companies being forced to resort to the use of generators and solar power. This is compounded by the fact that global fuel prices have been rising and are projected to continue to increase for the foreseeable future, while fuel prices in Zimbabwe are among the highest on the African continent.

High informality: Structurally the economy remains highly informalized. According to the 2024 First Quarter Quarterly Labour Force Survey Report by ZIMSTAT, informal employment constitutes 86.4% of total employment from 75.6% in 2019. The official unemployment rate is 20.5%. Youth (15-24 years) Not in Education, Employment or Training (NEET) was 49.0%. Informal employment is characterised by lower productivity, limited access to finance/credit, lower pay, limited social protection coverage, high levels of working poverty, and poor working conditions in general. More importantly, high levels of informality limit the capacity of the State to sustainably mobilise domestic resources and also effectively deploy micro and macroeconomic policies such as the National Budget and Monetary Policies to promote decent work. Countries or regions with high informality thus tend to grow less than their potential. High informality is, moreover, associated with high inequality: workers tend to earn less in the informal sector than formal sector peers with similar skills, and the wage gap between formal and informal workers is higher at lower skill levels. This explains why the large decline in informality in Latin America observed over the past 20 years was associated with significant reductions in inequality. There are a number of causes/drivers of informality multifaceted, varying from low economic development; to inequality of access to health, education, and other basic public goods; to the state of the legal and regulatory environment, notably in labour and product markets; to the design of the tax and social protection system; and to the quality of institutions. The high prevalence of informal businesses presents strong competitive pressures on the formal businesses whose costs are way higher than those of their informal competitors.

High levels of poverty and inequality: The poverty rate remains high, estimated at 39.8% in 2023¹ down from its peak of 49% in July 2020. This is far from Zimbabwe’s aspiration to reduce the share of the population below the food poverty line to 10% percent by 2025. The Gini coefficient has risen from 42 in 2011 to 50 in 2019 and 50.3 in 2023, implying that the gulf between poorer and richer in the population has widened². The El-Nino-induced drought has resulted in a significant reduction in crop production. The Ministry of Agriculture estimates that the 2023/24 national maize harvest was around 635,000 MT, just over 40% of the 10-year average. Total small grain production is estimated at 109,000 MT, bringing total cereal production to 744,000 MT, around 70% lower than the cereal harvest in 2023.The high levels of poverty, inequality, and food insecurity therefore necessitate greater public spending on critical productivity-enhancing and poverty-reducing sectors of the economy such as social protection, health, and education

Growing public indebtedness: The country remains in debt distress with total Public Debt rising from an estimated US$10.7 billion in 2020 to US$17.7 billion as at the end of September 2023 and to ZiG287.2 billion (US$21 billion) as at June 2024³ as shown in Table 1 according to official statistics. Of the total public debt stock, external debt amounted to ZiG168.5 billion (US$12.3 billion) (i.e., 58.7% of the total public debt stock) and domestic debt ZiG 118.7 billion (US$8.7 billion) (i.e., 41.3% of the total public debt stock). Of the total external debt stock, 80% are principal arrears, interest arrears and penalties. We owe our bilateral creditors ZiG 84.8 billion (US$ 6.2 billion), while we owe our multilateral creditors (including the World Bank, the African Development Bank, European Investment Bank, and Afreximbank) ZiG 42.9 billion (US$ 3.2 billion). We owe the World Bank ZiG million); the European Investment Bank ZiG 5.9 billion (US$ 400 million); and Afreximbank ZiG 5.3 billion (US$ 400 million).

Zimbabwe’s debt situation remains an impediment to both external sustainability and economic development. The unsustainable stock of external debt has constrained access to concessional financing and to international markets, retarded economic growth, and hampered socio-economic development. The huge public debt stock has reduced the availability of both local and external resources for social spending. The high public debt has crowded out public resources from key welfare-enhancing sectors such as health care, education, and social protection. According to the 2024 Mid-term Budget and Economic Review, interest on debt servicing during the first six months of the year amounted to ZiG368 million (US$26.9 million). Interest amounting to ZiG324.7 million (US$23.7 million) was paid on external debt; with the remaining ZiG43.3 million (US$3.2 million) being channeled towards domestic debt. Debt service exceeds total social spending at ZiG140.9 million (US$ 10.4 million). The high public debt has increased the country’s risk premium which makes it more expensive for businesses access offshore credit.

3.0       Health Situational Analysis

The country’s health sector continues to face myriad challenges that include: inadequate budgetary allocation and under-investment, high prevalence of communicable and non- communicable diseases, increase in the prevalence of mental health disorders/illnesses, depleted and demotivated healthcare workforce, inadequate and poor maintenance of healthcare infrastructure and ill-equipped hospitals, prohibitive cost of emergency and specialist services and a lack of decentralisation of such services. According to the World Health Organisation (WHO), in terms of the Universal Health Coverage (UHC) Service Coverage Index, the country has an index of 55.04 as at 2021 up from 54.00 in 2017. Zambia has an index of 55.84 while South Africa has an index of 70.95. The Universal Health Coverage (UHC) Service Coverage Index is measured on a scale from 0 (worst) to 100 (best) based on the average coverage of essential services including reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases and service capacity and access⁴.

Inadequate budgetary allocation and under-investment: The health sector has suffered from years of gross underfunding and investments, with public health spending accounting for a relatively small proportion of total government spending. Low public spending on health hurts citizens the most and results in high out-of-pocket spending and an inequitable health system that only guarantees access to those who are able to pay. Table 2 shows the sectoral spending performance of Zimbabwe for the period 2019 to 2024. Vote allocations and actual spending still remain below regional and global benchmarks.

⁴ https://www.who.int/data/maternal-newborn-child-adolescent-ageing/indicator-explorer-new/mca/uhc-service- coverage-index-(sdg-3.8.1)

Table 2: Sectoral spending targets and performance for Zimbabwe

Source: Calculations based on the National Budget statements.

Health spending as a share of total government expenditure, an indicator of the priority given to health. Health got Z$6.2 trillion or ZiG9.3 billion (10.6%), a decline from the 11.2% allocated in 2023, below the Abuja Declaration target of 15%. During the first half of the year, ZiG2.5 billion was spent on health, which accounts for only 6.4% of total public spending and 26.9% utilisation. Of the ZiG2.5 billion spent on health during the first half of the year, ZiG2.3 billion (i.e., 92%) went towards employment costs; ZiG166 million (6.6%) went towards hospital support; and ZiG66 million (2.6%) went towards Infrastructure Development. The Abuja target remains an elusive target for the country. The Government also spends a relatively small share of its Gross Domestic Product (GDP) on health care projected at 4.0% in 2024 up from 2.2% in 2023 (see Table 3). Per capita health spending on health is however expected to increase to US$71.8 in 2024 up from US$40 in 2023.

Table 3: Trends in Public Health Expenditure, 2016-2024

Source: Calculations based on Ministry of Finance figures.

The inadequate public financing of health has resulted in an overreliance on out-of-pocket and external financing which is highly unsustainable. The health sector benefited from US$72.3 million disbursed during the first quarter of 2024 by development partners. With the United States Agency for International Development (USAID) disbursing US$65.6 million, and support from the Global Fund of US$3 million towards HIV/AIDS, malaria and tuberculosis prevention, maternal and child health programmes. Under the Additional Financing Health Sector Development Project, the World Bank disbursed US$2.6 million to strengthen the country’s health sector through the results-based financing initiative. In addition, the People’s Republic of China donated equipment and consumables for respiratory and critical care medicine speciality to Parirenyatwa Hospital, as well as handed over the Anti-Narcotics Laboratory to Government in January 2024.

In countries that are highly dependent on external aid, health priority in government spending tends to fall in line with the increased aid. Development assistance for health has crowded out government resources and created donor dependence. Women, girls, children and people living with disabilities need more health care, but they also are more likely to be poor. For instance, women constitute 52% of the total population. High out-of-pocket health care expenditures threaten their health, financial and economic security. Empirical evidence has shown that higher out of pocket in healthcare exacerbates household poverty especially among women-headed households. Female-headed households face higher and increasing multidimensional deprivation than male-headed households, especially when the head is widowed or divorced.

According to the WHO Global Health Expenditure Report 2023, public spending on health had increased across the world, except in low-income countries where government health spending decreased and external health aid played an essential supporting role. Low-income countries accounted for only 0.24% of global health expenditure, despite having an 8% share of the world’s population.

Table 4: Sources of Health Spending (%)

Source: https://apps.who.int/nha/database/country_profile/Index/en

In terms of the key social determinants of health such as water and sanitation (WASH), Government spent ZiG382 million during the first six months of 2024 representing 0.08% of GDP which is way below the 1.5% of GDP benchmark set under the eThekwini Declaration (2008). WASH access increases women and girls’ opportunities to improve health and wellbeing, to be educated, and to generate income. The lack of reliable access to clean water and sanitation services increases women’s vulnerability to various health risks. They may be more prone to waterborne diseases due to inadequate sanitation practices or limited access to clean water for personal hygiene and cooking. This can have long-term consequences for their overall well-being and the well-being of their families. Addressing the gender impact of poor water and sanitation requires a gender-sensitive approach. This includes ensuring that water and sanitation facilities are designed to meet the specific needs and safety concerns of women and girls. It also involves promoting women’s participation in decision-making processes related to water and sanitation planning and management. Investing in gender- responsive water and sanitation infrastructure can have multiple positive impacts. It can reduce the time and physical burden on women and girls, empower them to pursue education and income-generating opportunities, improve their health and well-being, and contribute to gender equality and women’s empowerment overall.

Agriculture got Z$4.3 trillion or ZiG6.5 billion, which is 7.3% of the total votes and is below the Maputo Declaration target of 10%. By the first half of the year, Government had spent ZiG4.5 billion representing 11.6% of total spending and 69.1% utilisation. The Public Service, Labour and Social Welfare which is responsible for social protection got ZW$2.4 trillion, which is 4.1% of the total votes and 1.5% of GDP. According to the Social Policy for Africa Agreement (2008), African governments must spend at least 4.5% of GDP on social protection. By the first half of the year, Government had spent ZiG140.9 million for social protection representing only 0.03% of GDP. Education got the highest vote at Z$10.2 trillion (ZiG15.4 billion) constituting 17.7% of the total vote allocations, this is still below the Dakar Declaration target of 20%. However, during the first half of the year the Government spent ZiG6.7 billion towards provision of education (both basic and higher) representing 17.6% of total public spending during the period.

Table 5 shows the converted budget and budget utilisation during the first half of 2024. Vote allocations and actual spending reveal budget priority by the government. As shown in Table 9, the government is prioritising education, health, agriculture and defence and security. The low budget utilisation for critical departments such as Health and Child Care (26.9%); Public Service, Labour and Social Welfare (6.8%); and Audit Office (6.8%) is a major cause for concern given the parlous health, poverty and labour market situations.

Table 5: 2024 Converted Budget and Budget Utilisation

Depleted and demotivated healthcare workforce: Health workers are the backbone of every health system. Healthcare provision depends very much on the people who provide the services to the citizens. Over the years, attention and support to the healthcare workforce has not received the priority it deserves. Zimbabwe is one of the low-income countries in which the number of health workers is less than 23 per 10,000 people, a critical threshold below which essential health services are difficult to deliver⁵. The parlous human resource situation reflects a number of factors that include: inadequate number, mix and distribution resulting from inadequate output from training institutions and the outward migration of health workers to other countries. In particular, the outmigration of health workers has been driven by heavy workloads, inadequate compensation exacerbated by the high inflation, limited career development prospects, and challenging working conditions. The outmigration of health workers has led to longer waiting times, reduced patient care time, and compromised health outcomes. District level health facilities have been the worst affected by the outmigration of health workers. Specialists who migrate take with them valuable expertise, experience, and knowledge. This loss has impacted on the quality of health services, particularly in specialized areas where their skills are in high demand. The remaining depleted health workers are not adequate and are overburdened due to the many different services being offered at the facilities. Health workers are therefore susceptible to burnout and job dissatisfaction due to long working hours, high workload, emotional stress, and limited resources. These issues affect staff morale and their ability to provide quality care.

Inadequate infrastructure and ill-equipped public healthcare facilities: Public health infrastructure is grossly inadequate to cater for the health-care demands of the citizens. Most health facilities especially in rural areas lack essential equipment, medications, and supplies necessary for maternal, newborn, child health, reproductive health, and nutrition services. This affects the ability of health workers to diagnose, treat, and manage conditions effectively. Theatres and laboratories are usually not functional or do not have the staff to do the tests as a result people usually get these services from the private sector as qualified health workers are not being retained resulting in gaps in service delivery and many cases of poor service, negligence, wrongful diagnoses etc. A number of patients are still enduring having to travel inordinately long distances to access primary health care facilities. Moreover, a number of rural clinics face water and electricity challenges.

Shortages of essential drugs and medical supplies: Medicines are vital elements to health- care, and access to medicines is a fundamental human right. The World Health Organization (WHO) defines essential medicines that ‘satisfy the population’s priority health care needs.’ The prevailing essential drugs shortages bring significant challenges to the health care system. The causes of the shortage include: supply-side constraints, demand-side issues, and regulatory issues. Supply-side constraints consist of manufacturing problems, unavailability of raw materials, logistic problems, and doing business bottlenecks.

Access to functioning medical equipment in public health facilities remains a challenge in Zimbabwe. Medical equipment is an important component of a health system and a vital tool used by health professionals to prevent, diagnose, monitor and treat diseases as well as during

⁵ https://www.afro.who.int/countries/zimbabwe/news/zimbabwe-conducts-health-labour-market- analysis#:~:text=Zimbabwe%20is%20one%20of%20the,services%20are%20difficult%20to%20deliver.

rehabilitation after a disease or an injury. Making sure that health facilities have adequate supplies of equipment is essential in making people have confidence in health services provision. The World Health Organization (WHO) estimates that 50%–80% of medical equipment in developing countries does not work, which creates a barrier to the delivery of services to patients.

Rising incidence of Non-Communicable Diseases (NCDs) and Injuries from Accidents: The rising incidence of NCDs constitutes a major burden of disease with significant socio- economic impacts on the country. This is being driven by interplay of underlying social determinants, lifestyle choices, and physiological risk factors. The major risk factors which have been associated with NCDs are tobacco consumption, alcohol use, physical inactivity, and unhealthy diet. Population aging, globalization, and urbanization as well as nutritional factors have also been identified as determinants of NCDs prevalence across the world. Additionally, inherent factors such as age, genetic predisposition, gender, and race have been shown to influence the incidence of NCDs⁶.

According to the World Health Organisation (WHO), Zimbabwe has the highest death rate from road traffic injuries estimated at 41.2 deaths per 100,000 population as at 2019 . Statistics from the Traffic Safety Council of Zimbabwe (TSCZ) show that 14,600 people died and 74,000 were injured in road accidents between 2015 and 2022. TSCZ’s annual reports show that Zimbabwe had the highest road accident peak in 2018, when 58,738 incidents were recorded followed by, 51,107 in 2022 and 45,791 in 2021.

Under-developed and poorly resourced emergency services: Emergency medical services in Zimbabwe remain relatively under-developed and under-resourced especially in the rural areas. Ambulances are not adequate and are not equipped with the requisite facilities to enable the offering of quality response especially during emergencies. Most districts do not have adequate ambulances as usually only one is relied on for referral of patients as well as admin requirements of the health facility. Even in urban areas, there is a serious shortage of ambulances and their charges are required upfront and not affordable. In rural areas, sometimes ambulances do not have fuel to enable them to transport patients to the next level of care and this results in delays. Communities have to make alternative transport arrangements which can be very costly. Palliative care services are only supported by Village Health Workers and Home-Based Care Workers in certain rural areas. Urban areas have limited support and families have to rely on paid Nurse Aids for support.

High healthcare costs, including user fees, co-payments, and medication expenses make healthcare services unaffordable for individuals and households, particularly those with limited financial resources. Affordability concerns lead to delayed or foregone care, compromising health outcomes. Moreover, the cost of healthcare extends beyond medical expenses, out of pocket costs can deter individuals from seeking timely treatment and care. The cost of medication particularly for chronic conditions has a significant financial burden for individuals and households. High medication costs of drugs often lead to non-adherence to prescribed medication or individuals seeking alternative and potentially unsafe sources for medications.

⁶ https://johpec.lse.ac.uk/articles/36

In most rural health centres, the only cancer services on offer are screening using VIAC and referrals for further tests, treatment and therapy at district or provincial level. Costs related to cancer screening and treatment are beyond the reach of many.

Mental health crisis: In 2022, the World Health Organisation reported that Africa is home to six of the top ten countries with the highest suicide rates namely: South Africa, Lesotho, Eswatini, Mozambique, Central African Republic, and Zimbabwe. A mental health crisis is silently plaguing the country. While the number of people affected by mental health is on the rise, mental health support infrastructure remains bleak. According to the WHO, Zimbabwe only has 19 psychiatrists and 35 clinical psychologists against a population of 15.2 million. Suicide prevention is rarely prioritised in national public health programmes, just as mental health is not often covered in health insurance policies.

4.0       Conclusion and Key Recommendations

While the country has made some progress in terms of ensuring healthy lives and promote well-being for all at all ages, challenges still remain. The erratic growth rate and high levels of informality have contributed to the weak domestic resource mobilization capacity. This has adversely affected public investments in critical productivity-enhancing and poverty- reducing sectors of the economy such health, education, social protection and infrastructure. Many Zimbabweans still lack access to basic primary healthcare services like reproductive, maternal, antenatal care, facility-based childbirth, contraception, and new-born and child nutrition. The rising incidence of poverty, food insecurity, rising informality, increasing un and underemployment are negatively affecting health outcomes. It is particularly important to broaden the tax base by dealing with the problem of informality and to explore all possible avenues of domestic resources mobilization to close the persistent health financing gap to enable the country to achieve UHC and the SDGs. It is important to ensure that the health system is adequately resourced and that resources are efficiently and optimally utilised.

• Government must commit to allocating and spending at least 15% of the total budget towards the sector in line with the Abuja Declaration target. The health budget remains grossly inadequate to fund the critical needs in the health sector. The current health financing model also remains unsustainable as it heavily relies heavily on external financing as well as OOP financing. Notwithstanding the huge external support from development partners, there is still a huge financing gap in the health sector in the country which calls for greater commitment by the Government to sustainably address it. In line with the Presidential mantra that ‘nyika inovakwa nevene vayo’, it’s important to increase public spending in the health sector for the attainment of universal health coverage (UHC) that ensures that no one and no place is left behind. This implies in line with regional and global best practice that government must bear the greatest burden in terms of health financing. No country can make significant progress towards UHC without relying on dominant share of public funds. Public funds are essential for UHC. Empirical evidence has shown that government financing is the most efficient and equitable way to fund health coverage.

• Address the human resources situation. The health worker establishment needs to be reviewed in line with the population growth, growing disease burden and health There is need to ensure the sustainability and competitiveness of the health workforce, particularly to secure adequate numbers of health professionals in remote areas as well as improving working conditions, remuneration and career prospects, especially for nurses, to support retention. Appropriate incentives must be designed to ensure equitable distribution across urban and rural areas ensuring access to under‐served populations. Moreover, it is important to absorb Village Health Workers onto the government payroll system.

• Strengthening Manufacturing Capacity to Improve Access to Quality-Assured Essential Medicines. Progress towards UHC is dependent on the availability of quality- assured essential medicines. However, ensuring a sustainable supply of these medicines can be difficult. Supporting pharmaceutical manufacturers to achieve compliance with international quality standards such as WHO PQ (WHO, 2017) can help to address issues related to the supply of essential medicines. There is need to build the capacity of local drugs manufacturers such as the National Pharmaceutical Company and CAPS. The main challenges weighing down on the sector include: low levels of productivity and capacity utilisation; high unit costs; limited access to and high cost of finance/credit; limited access to technology; antiquated equipment; fragmented and poor procurement and supply chain systems; low purchases by Natpharm; cumbersome registration procedures; low investments in research and development as well as intellectual property; and low public spending on the health sector in general.

• Improve access to sexual and reproductive health services, especially for Limited access to sexual and reproductive health services imply that most women (especially in the rural areas) cannot choose if and when to have children. This can increase women’s care load and exacerbate existing inequalities in caregiving. The National Budget must therefore improve access to sexual and reproductive health services, especially for adolescents through providing funding for sexual and reproductive health education, counselling, contraceptive provision, community mobilization and female empowerment strategies. Providing access to these services improves development outcomes and promotes health equity. It has been shown that improved access to sexual and reproductive health services, is associated with a reduction in the time women spend on Unpaid Care and Domestic Work (UCDW), and the time girls spend in school. Strengthening sex education is a primary strategy for achieving improved adolescent sexual health outcomes through improving sexual health literacy, building awareness, confidence and skills.

• Invest more in addressing mental health issues in Inadequate financing for mental health is the biggest limitation, adversely affecting efforts to expand Zimbabwe’s mental health workforce and capacity. The country must prioritise the implementation of the Framework to Implement the Comprehensive Mental Health Action Plan in the WHO African Region through increasing public expenditure on relevant services, and mobilising resources from partners.

• Combating the scourge of NCDs. As treatment of NCDs is very expensive, prevention programs should be the way forward to keep citizens healthy and productive. Early diagnosis and management of NCDs as well as limiting exposure to some major risk factors have proven effective in tackling NCDs. Focusing on lowering the risk factors linked to NCDs is an effective method to control these diseases. Reducing significant modifiable risk factors include cigarette use, hazardous alcohol consumption, poor diets, and lack of physical activity. Mass and social media campaigns to educate the population about risk factors of NCDs such as tobacco use, alcohol abuse, unhealthy diet, and physical inactivity must be undertaken. There is also a need for the mobilization of resources to ensure that high-risk individuals access routine cancer screening and receive vaccination against hepatitis B and human papillomavirus (HPV) to reduce their chances of having liver and cervical cancer

respectively. A strong, well-funded and accessible primary health system keeps people healthier and out of hospital by supporting them to manage their health issues, including chronic conditions, in the community. This reduces reliance on costly acute care, such as specialists, emergency department or other hospital services.

• Leveraging the digital economy. Enhancing the health service delivery through leveraging digital economy platforms such as telemedicine is also critical as it helps to reduce costs and enhance efficiencies. In many countries, the use of electronic health records, telemedicine, and digital platforms has improved efficiency and patient outcomes. This technological integration could serve as a valuable lesson for Zimbabwe in enhancing its healthcare infrastructure.