Research for stronger health systems during and after crisis

Assessing progress towards equity in health: Zimbabwe 2014

Training and Research Support Centre and Ministry of Health and Child Care, Zimbabwe (2014) Zimbabwe Equity Watch 2014, TARSC, MoHCC, EQUINET Harare

This 2014 Equity Watch report from Zimbabwe continues the work done in the 2008 and 2011 reports to review progress in delivering on policy commitments to promote health equity. The report is by ReBUILD Affiliate partners TARSC and MoHCC (members of the Regional Network for Equity in Health in East and Southern Africa, EQUINET) and this 2014 report was supported and drew on evidence from the the ReBUILD funded project Rebuilding the foundations for universal health coverage with equity in Zimbabwe.

The full Equity Watch Report: Assessing progress towards equity in health: Zimbabwe 2014 can be downloaded here via the TARSC website.

Key extracts are below.

About the Equity Watch

An Equity Watch gathers, organises, analyses and reports evidence on the progress being made in advancing equity in health. Equity Watch work is being implemented in countries in East and Southern Africa in line with national and regional policy commitments. In February 2010 the Regional Health Ministers Conference of the East, Central and Southern African Health Community (ECSA¬HC) resolved that countries “Report on evidence on health equity and progress in addressing inequalities in health”.

Using available secondary data, the Equity Watch is implemented by country personnel with support and input from EQUINET. It aims to assess the status and trends in a range of priority areas of health equity and to check progress on measures that promote health equity against commitments and goals.

Equity Watch reports were produced in Zimbabwe in 2008 and 2011, using a framework developed by EQUINET in cooperation with the ECSA–HC and in consultation with WHO and UNICEF. This 2014 Zimbabwe Equity Watch updates the evidence using in the same framework, and including areas identified by stakeholders in Zimbabwe as important for achieving equity in Universal Health Coverage (UHC). The report introduces the context and provides evidence on selected parameters of: equity in health, household access to the resources for health, equitable health systems and global justice. It shows past levels (1980–2008), current levels (most current data publicly available for the past 5 years, (2009-2014) and comments on the level of progress made towards health equity. It provides a coloured bar indicating what the situation is, and whether broadly:

It uses mixed yellow-green and yellow-red colours where the findings are mixed, but with overall signs of progress or decline respectively.

We explore the distribution of health, ill health and particular determinants, including those relating to employment, income, housing, water and sanitation, nutrition and food security, and those within the health system. The Equity Watch examines the fairness of resource generation and allocation, and the benefits derived from consuming the resources for health. The 2014 Equity Watch includes available evidence on the private for profit sector in health. We also explore the governance of the health system, given that the distribution and exercise of power affects how resources are distributed and strategies designed and applied towards ensuring access to the resources for health. This 2014 Equity Watch shows the progress made in achieving equity in the health Millennium Development Goals and in achieving goals of equity in a universal health system.


Key Messages:

 This report continues the work done in the 2008 and 2011 Zimbabwe Equity Watch reports to review progress in delivering on policy commitments to promote health equity. Progress has been made in improving equity in a number of areas, in:

  • The inclusion of the right to health care and to health determinants in the 2013 Constitution.
  • A fall in overall inequality and closing of gaps in wealth between rural and urban areas.
  • High primary enrolment and gender parity in education, in line with Millennium Development Goal (MDG) targets, and
  • Widening access to land and food availability.

There have been overall improvements in child survival and nutrition, more recently in maternal mortality; a significant reduction in HIV prevalence, and improved immunisation coverage, maternal health, HIV and sexual and reproductive health (SRH) service coverage, with a fall in inequalities for services such as immunisation and antenatal care (ANC) that are closer to reaching universal levels.

However the levels of under-five and infant mortality rates are far from MDG targets, especially for poorer households and after infancy. There are still wide gaps between current levels of child malnutrition and maternal mortality compared to MDG targets. There are persistent disparities by wealth and mothers education in the uptake of SRH and HIV prevention and treatment services; and chronic conditions (NCDs), present a rising and still relatively unmanaged health challenge.

Inequalities in health arise largely due to social inequalities in the factors that affect health. There are widening inequalities in wealth within urban and rural areas, with increased urban poverty, and with a more recent growth in rural wealth without a decline in rural poverty. There is persistent gender inequality.

Social inequality reflects insecurity of incomes, food poverty in urban areas and gender and wealth inequalities in rural agriculture, contributed to by increased reliance on commercial food markets and rising food prices. Cost barriers to enrolment exist in entry to education, in early childhood development (ECD), and in completing secondary schooling, both of which have implications for improved health.

Shortfalls in the provision of functional improved water and sanitation are associated with outbreaks and high prevalence of preventable disease.

Within health services, improvements in coverage and equity have been contributed to by:

  • The presence of a literate population, an active health civil society and revival of the village health worker programme to support health promotion and service uptake.
  • Significant improvements in medicine availability at primary care and district level, and in the training and retention of nurses, doctors and pharmacy personnel in public services.
  • Support for HIV and AIDS and for malaria and TB control services, including through an earmarked tax (the AIDS Levy).
  • Removal or reduction of fees in public and not for profit services for pregnant women and children, with evidence of a reduction in cost burdens to households.
  • Information and service investments implemented in the results based financing programme contributing to capacities for improved use of funds.
  • Pooling of external funding in the Health Transition Fund with spending aligned to national goals.
  • Updating and costing the health care entitlements at primary care and district level, and
  • International partnerships and negotiations to support health services.

There are challenges to sustain these gains and to address disparities in health and access to care.

Most importantly, domestic health financing has fallen below the Abuja commitment and below per capita levels set in WHO guidance. Domestic health financing is inadequate to meet the core package of services for the health MDGs and below the level needed for the essential health benefit identified by Ministry of Health and Child Care. This has made the country highly dependent on external funding for key areas of health delivery, particularly for essential medicines and supplies, and for health worker retention incentives for the primary health care and district health services that are critical for the low income majority. Inadequate financing has been associated with low levels of investment in, and inadequacy of, personnel for preventive services, including to prevent the escalation of future costs of NCDs, by acting early to prevent them.

 The evidence points to other challenges: In the public sector there are gaps in deployment of personnel to districts with higher levels of poverty; in supplies for chronic conditions and in emergency supplies, transport and services. There is weak monitoring and social accountability, and weak regulation of cost escalation, inefficiencies, segmentation and barriers to financial protection in the private health sector.

Closing gaps in coverage and outcomes calls for strengthened investment in PHC, including to:

  • Strengthen nutrition interventions, supporting community health workers to encourage exclusive breastfeeding, nutritious weaning foods and uptake of growth monitoring to identify and link children in vulnerable urban and rural situations with health and other support.
  • Sustain the availability of medicines and personnel in primary care services.
  • Intervene from adolescence onwards in improving continuity in access to SRH and maternal health services, encouraging earlier more frequent uptake of antenatal care on the one hand, and improved referral for complications in rural areas and lower income households on the other.
  • Formalise Health Centre Committee (HCC) roles at system level, widen health literacy, support VHWs and strengthen public involvement and accountability measures in the private health sector.
  • Improve tools for harmonised budgeting, planning, reporting and purchasing arrangements across the various public and external funds.

Universal systems are built over years, organised around a shared vision of a national unified health system and with deepening social and state awareness, advocacy and capacities to progressively implement Constitutional rights and pro-equity health policies that are relevant for the next decade.

The evidence indicates that mobilising new domestic resources will be a key and critical task, for health promotion, detection and management of NCDs, to ensure supplies and personnel at primary care and district services, and to support outreach for continuity of care, including through schools, communities and workplaces.

Sustaining and widening efforts to achieve universal coverage of key services based on delivery of universal entitlements will need to be funded through mandatory pre-payment financing, such as by taking forward the policy proposals in Zimbabwe Agenda for Sustainable Socio-Economic Transformation (ZimAsset) to improve progressive tax funding, including from earmarking VAT and excise taxes, with measures to ensure equity, efficiency, transparency and accountability in their management. Needs based resource allocation would need to apply to new resources, so that no district receives reduced funds. Measures need to be applied to strengthen monitoring of service gaps and to build capacities to absorb and use funds effectively. A dialogue with the private health sector to co-ordinate a partnership aligned with national goals will need to be based on better information and public domain reporting, including on costs and performance.

As many of the determinants of improved health equity lie outside the health sector, improving health equity also depends on intersectoral processes that advance ‘health in all policies’, to address ‘the causes of the causes’ or underlying determinants of poor health outcomes, including:

  • Identifying specific measures and targets for improving employment and income security, for supporting food production and markets and for addressing gender equality in access to land, credit and inputs for food production and for encouraging nutritious weaning foods;
  • Exploring options for ensuring ECD enrolment in low income households;
  • Improving quality of, enrolment in and completion of secondary school and supporting costs for the poorest children.
  • Investing in rehabilitation of public urban water supplies and active promotion of improved sanitation with a one household one toilet campaign in all areas.
  • Identifying risks and implementing measures to raise social awareness and reduce exposure to risk factors causing chronic diseases, through environmental measures, road traffic systems and regulation of marketing of unhealthy food, tobacco and alcohol, and
  • Pooled medicine procurement and tariff measures aligned to policy support for local medicine production, including reduced import costs of inputs for local pharmaceutical production.

Download the full Equity Watch Report: Assessing progress towards equity in health: Zimbabwe 2014.