Open letter to President Emmerson Mnangagwa

Writes Itai Rusike (Executive Director of Community Working Group on Health)

Now that the elections are over, the people of Zimbabwe expect the fulfilment of the election manifesto, in which you promised massive improvement in health infrastructure; more health personnel; accessible and affordable medicines; free medical care for cancer patients; at least one hospital per district, improved health services in resettlement areas, reduction of hospital fees by 50% and pursuing the Health for All policy, among others.

We were over the moon when you made very promising pronouncements which include the National Development Strategy, (NDS1) which aimed to make the country an upper middle-income economy by 2030, and the tagline `leaving noone and no place behind.” As the Community Working Group on Health (CWGH), we summarize this as primary health care, (PHC) with clear intentions for the attainment of Universal Health Coverage (UHC) and therefore the Sustainable Development Goals (SDGs), which are due in the next 7 years, i.e 2030. It is only a healthy nation that can deliver an ambitious national development agenda.

For this reason, the CWGH and its network members would like to urge the renewed and reinvigorated government to immediately shift focus to real developmental issues, particularly taking into account the dire need to improve health service provision for the benefit of ordinary Zimbabweans as articulated in the pre-elections.

It is undeniable that the deplorable state of the country’s health system requires urgent attention, especially giving priority focus to revitalizing the PHC concept and philosophy that once worked so well and gave Zimbabwe health leadership within the SADC and beyond in the yesteryear.

As ensrined and articulated so well in the Nation’s Constitution, (2013) a whole of government approach will ensure adequate addressing of the social determinants of health to achieve UHC, thus enabling every Zimbabwean equitable access to essential and quality health services without facing financial hardships. Zimbabwe in our considered view needs sustained investments in primary health care to rise up to the occasion and attain the health financing, health governance, and therefore health care delivery goals and so enable the health system to urgently close the current gaps that may hinder the country’s attainment of its set goals and targets.

Presently, health service provision as prescribed by the World Health Organization’s six building blocks is found wanting within the public sector which includes central government, local government, the church-run and uniformed forces services. This compromises access of up to 80% of the population that is served within public health institutions. Meanwhile, we are not sure of the quantity and quality of services accessed by the remainder 20% who can afford the private sector fees. Infrastructure in most of the country’s hospitals and clinics is dilapidated, outdated, and grossly inadequate considering the increased population and disease profile. This translates to limited access to healthcare facilities and poor quality of care.

Similarly, most equipment for diagnostics, care, therapy, monitoring, rehabilitation, and palliation is non-functional or obsolete. This puts additional strain on the available healthcare workers who have to work manually while risking patients’s welfare as well as their own. Medicines, surgical, and supplies are widely in short supply; doctors, laboratorians, pharmacists, paramedics, and nurses are inadequate and poorly motivated.

This is against a background of sustained inadequate funding to the sector from the national fiscus falling far short of the agreed Abuja Target of 2000 allocating at least 15% to health. Donor funding for Zimbabwe has also been dwindling and is in fact set to be switched off by 2030. This is of major concern as the problems in the health sector are compounded by the continued very high prevalence of largely preventable diseases as well as behaviour, lifestyle, environmental and basic water and sanitation issues.

All these could be drastically reduced if a combination of PHC, addressing the social determinants of health which as mentioned are Constitutional provisions which are just not being implemented. We wish to remind your new government Sir, that Zimbabwe has never achieved the 15% Abuja target since the declaration was signed in 2001, and to also point out that the target then 20 years ago, was to ensure at least 60% access to specific populations in the country to access selected maternal and child health services, AIDS, TB and malaria, diagnostic and treatment services which then were the most compelling health challenges.

As we move to UHC, and ”leaving noone behind” it is important that we come together for a clear and common understanding of the math, metrics and targets, so that the UHC and SDG targets are put in the context of our abilities and shortcomings. As the CWGH and our network members we stand ready to work with you and your teams as we take up your challenge Your Excellency to ”really roll up our sleeves” and get to the 100% mark.

The current quadruple or indeed multifaceted burden of disease and conditions, (communicable, non-communicable, injuries, HIV, maternal, peri-natal, neglected tropical diseases, cancers, mental, dental, substance abuse) is unmatched by the prevailing institutional capacities, management and health staff skills to adequatey detect and manage. These have individually or in combination translated into premature and excess mortalities across the ages, which in our view requires immediate attention.

The CWGH strongly reaffirms the full definition of health as articulated at the formation of the WHO in 1948 that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.

Zimbabwe is a signatory to the International Declaration on Primary Health Care, coconvened by both the WHO and UNICEF at Alma Ata in 1978, and which inspired and galvanized understanding, analysis, and action on health. Its adoption and implementation at our Independence in 1980 PHC is what gave us an enviable health delivery system which availed quality health services to the majority Zimbabweans that had been marginalized under colonial rule. We therefore strongly recommend revisiting PHC for getting our health system back up where it belongs.

In our region, and indeed in this country, the aspirations and content that were included in the 1978 declaration largely informed the early adoption of the PHC concept and philosophy at independence, and just 2 years post Alma Ata. The subsequent policies on health for all by the year 2000 saw Zimbabwe achieving remarkable health indicators just 10-15 years post-independence and assuming a health leader position in the African region. As CWGH we see a semblance of the same energy and are therefore hopeful that the renewed leadership will take us from Alma Ata to the Millennium Development Goals (MDGs unfinished business), to Abuja, and all the way to the SDGs within the next 7 years.

In recent years, many countries including Zimbabwe have adopted UHC as a national policy priority and have committed to directing government funding towards that goal. Ensuring sustainable progress toward UHC means that Zimbabwe’s public health financing system must urgently start generating sufficient, and largely domestic, resources to better finance its ailing health, social, and other systems that hold the broader determinants of health.

This will enable the achievement of health sector objectives within its macroeconomic and fiscal context, as well as fulfill the Constitutional provisions for all Zimbabweans. It is not only the level of government health spending that matters for sustaining health systems and enabling them to meet UHC goals, but also the efficient and equitable use of those funds. Public budget revenues, as well as the public financing systems that manage those funding flows, therefore play a crucial role in directing money efficiently, equitably, and effectively towards UHC goals and other health priorities.

We are hopeful that the new government will develop concrete actions not only to address the current and pressing health sector requirements but ensure that the impending transitioning out of major funders that has been announced is factored into the national planning for domestic resources mobilization for health and its determinants for the long haul.

We therefore urge you Mr. President and your new government to go well beyond the appending of signatures to regional and international declarations; but revisit the various declarations over the past 40 years for a critical analysis of what worked and why we fell short of significant health goals and thus what we can carry forward to leave no one behind. We call for an economic order that would serve the attainment of health and reduce inequalities in health nationally, while also recognizing that the promotion and protection of people’s health in both public and private sectors is essential for socio-economic development. Our focus is thus on UHC as the end and PHC as the means.

While we appreciate the role and support of the donors, we ephasize that it is risky and unsustainable for a country to depend on external partners as donors can withdraw financial support anytime should their interests shift for some reasons. They also can never address all the nation’s needs. The Paris Declaration on aid effectiveness refers. None of the donors have kept their part of the bargain, none have nationwide reach to address even the indicated diseases they support, hence the adverse health indicators. As your new government is confronted by the transitioning out of health donors, we draw your attention to the fact that presently, about 90% of medicines used in the public health delivery system in Zimbabwe are funded by donors, a national security threat should the external partners pull the plugs. This also says a lot about how far we are as a country from fully embracing PHC and therefore our progress towards UHC, and leaving noone behind”.

Your new goverment, Your Excellency, therefore needs to design and implement new and innovative domestic health financing policies to fund a strenghtened primary health care strategy to achieve UHC. We have over the years profferred several options and strategies that Zimbabwe can explore for innovative mobilization of resources building on best practices in global health financing to boost public spending on health without undermining fiscal sustainability.

These include decentralisation and devolution with increased transfers from the central government to local governments and peripheral health facilities on the basis of needs and performance as well as the establishment of a mandatory national health insurance system including cross-subsidies from richer to poor categories.To this end we wish to inform you, Your Excellency that we have done considerable work in revitalization of PHC for UHC, initiated national dialogue on health financing including on the national health insurance and stand ready to share the progress for your new government’s consideration and continued work as time is not really on our side.

We also take note and urge you to continue the Diaspora engagement you started under ”Zimbabwe is open for business” in bringing back remittances in support for the revitalization of the health delivery system and the technical expertise through mentorships and skills transfer programme to strengthen the same system that was weakened by their departure. This calls for heightened management and governance capacity at the national and sub-national levels for accountability, transparency but also importantly effectiveness and efficiency in utilizing the mobilized financial, other material and human resources.

We also applaud you on past efforts and actions in establishing new health facilities, in ensuring utilization of devolution funds for improving infrastucture and services and in the recent acquisition and transport including air transportation to service the hard to reach areas and sincerely hope these are continued in the new government to ”indeed leave noone and no place behind” by 2030.

The CWGH calls on the new government to urgently address the proximal determinats of the health of all Zimbabweans including but not limited to shortage of health personnel by unreservedly lifting the freeze on employment of health staff, and rationalizing the balance of preventive, clinical, rehabilitative, palliative and support staff in line with PHC.

The new Health Services Commission must address the glaring management and governance issues in health, and ensure that the employer of choice for all health workers is central government was the case in the past. Managing a professional workforce requires technical skill and capacity, but also humane traits and compassion that we find missing in the public health sector. This largely accounts for the mass exodus of our highly trained health workers to offer their young productive lives elswhere. Furthermore, these workers require the tools of the trade, which in turn must be effectively and efficiently managed, be they infrastructure, medicines, equipment, ambulances, service vehicles, and new technologies to make their work less tedious and in line with current best practices than it currently is.

Zimbabwe is one of the few countries still to establish a National Public Health Institution despite a number of offers of support in its set up. We implore you your Excellency to ensure that during the life of your government and as the Health services Commission starts their tenure, this institution be prioritized.

This is in view of the country’s experiences during Covid-19 and the ensuing fragility of the health system, the worsening of the aformentioned multifaceted disease burden in the country against a background of inactivity of both the Public Health Advisory Board and Primary Health Care Taskforce, all of which demand a strong public health approach to health service delivery. We therefore applaud the efforts that went into updating our Public Health Act under your stewardship and how your application of its provisions together with the Civil Protection Act on national disaster management supported and demonstrated your leadership during the Covid-19 pandemic.

We now urge your new government to utilze these successes to futher strengthen the health governance and management, particularly in ensuring sustainability and perfomance of strategic institutions. These include but are not limited to the Public Health Advisory Board, the Primary Health Care Taskforce, the National AIDS Council Board, the Regualtory Bodies, Research Institutions, Training Institutions, Hospital, Provincial, District Managemnt Boards and the local health governance structures including the Health Center Committees. These could all be better supported by a National Public Health Institute and overseen by your Health Services Commission.

In Zimbabwe, community health structures exist to assist in health promotion, uptake of preventive services and provision of health care services close to where the people are. We have supported governance structures from the Health Centre Committees, District Management Teams and the Public Health Advisory Board, the Primary Health Care Taskforce and the Parliamentary Portfolio Committee on Health, and Budget at national level.

However, as the country embraces the very ambitious national development targets, the SDGs and therefore UHC, we strongly recommend the developmet of a policy on integration and movement from the programme and donorbased approach of health programming to a comprehensive and nationwide coverage of health interventions. Community-Based Workers; Village Health Workers, Community Based Distributors, Home Based Care Workers, Youth and Women’s Affairs and Envirnmental Health Technicians must all be trained in both UHC and the SDGs for full community participation in health and development agenda. We therefore urge the newly elected govermnet to fundamentally support and strengthen the role of local leadership and community structures for health interventions to bear fruit. To this end we stand ready to work closely with your teams as relevant your excellency.

It is our considered view that Your Excellency, that your new government needs to quickly embrace the Health in All Policies, address the Social Determinants of Health (SDH), and ensure a whole of society approach in terms of the call for Health for All and Leaving No One Behind. We condemn the current status of unregulated urbanization which demotes rather that promotes health and longevity, and is not in line with the nation’s development agenda. People need decent housing, food security, provision of safe and clean water, education, good modes of transport and gainful employment to live normal and healthy lives, free from social evils that include substance abuse and socio-economic strife. We also urge the traditional leaders, churches and other religions to embrace the national health and developmental agenda, identify and remedy the current ills that are affecting especially women and children. Health equity and social determinants are acknowledged as a critical component of the Post-2015 and sustainable development goal (SDG) agendas and for the push towards the progressive achievement of UHC.

We take this opportunity to remind you sir that some Zimbabweans when ill still walk over 30 kilometers to the nearest health facilities to seek treatment especially in the remote locations, farming and resettlement areas defeating the noble concept of a clinic within every 10 km radius. Some are transported in wheelbarrows and scotchcarts either because there are no ambulances, or service vehicles, and if available it has no fuel, or the roads are impassable.

When they reach the facility, there are not enough nurses, midwives, surgeons or other trained staff, no medicines, especially for chronic conditions, no gadgets for checking temperature, blood pressure and other parameters, and if requiring some procedure such as plaster, wound care, the capacity at local level may not be there.

This means Zimbabweans are being denied their right to health although Section 76 of the Constitution clearly states that: “Every citizen and permanent resident of Zimbabwe has the right to have access to basic health care services, including reproductive health-care services”. We therefore advocate for all new appointees to work closely with existing staff, take positions of authority seriously and take the nation to your vision 2030. We reiterate our commitment as the CWGH and our network membership to work with your new government, trusting your leadership and guidance. Once again Sir, our hearty congratulations!

Community Working Group on Health (CWGH) is a network of 40 national membership based civic organizations focusing on advocacy, action, and networking around health issues in Zimbabwe. It was founded in 1998 and is registered as a PVO 01/2014.