Health Delivery Systems in the Crisis and Beyond
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Dr Magure investigates the role of health delivery systems and looks at how health can be delivered in the future. Presented at 'Moving Forward with Pro-poor Reconstruction in Zimbabwe' International Conference, Harare, Zimbabwe, (25 and 26 August 2009)
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Health Delivery Systems in the Crisis and Beyond
- 1. Health Delivery Systems in the Crisis and Beyond Presented By Dr. T. Magure MBCHB,MPH,MBA
- 2. Introduction • Zimbabwe's economy has declined since the late 1990s, with real GDP estimated to have declined by almost 30% between 1997 and 2003 • In 2006, Zimbabwe had an estimated GDP of 3.146bn USD and a projected GDP growth rate of -4.4% • There has been a marked decline in public health expenditures that have resulted in deterioration of health facilities
- 3. Situation Analysis • Zimbabwe’s health status has deteriorated since 1992 • The crude death rate dropped from 10.8 in 1982 to 6.1 in 1987 then rose to 9.49 in 1992 • The overall crude death rate was 17.2/1000 population in 2007
- 4. Situation Analysis continued… Estimated Crude Death Rates (CDR), Zimbabwe, 1980-2007 25 20 15 10 5 0 1981 1983 1987 1985 1989 1993 1991 1997 1995 1999 2003 2001 2005 Year CDR (per 1000)
- 5. Situation Analysis continued • According to the ZDHS, the infant mortality rate declined from 65 deaths per 1,000 live births in 1999 to 60 in 2005/6 • The under-five mortality rate declined for the same periods from 102 deaths per 1,000 live births to 82 • Life expectancy has decreased from 58 years (CSO, 1982) to an estimated mid-30s (UN and US Bureau of the Census, projection model; MOHCW 2004)
- 6. Situation Analysis continued • New TB cases increased from 61 per 100 000 in 1986 to 485 in 2001 • Malaria remains a major public health problem, accounting for 740 000 clinical cases and 3000 deaths • In the last 3 years EPI coverage rates have been declining rapidly due to poor health system performance
- 7. Situation Analysis continued… Trends in the estimated adult (age 15 to 49 years) HIV and AIDS prevalence and incidence, Zimbabwe, 1980-2007 35 30 25 20 15 10 0 5 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 Year Percent Adult prevalence Adult HIV Incidence Source: Draft National Health Strategy 2008
- 8. Situation Analysis continued • The country has seen a decline of adult HIV prevalence from 24.5% in 2004 to 15.6% in 2006 • This is an area which government and funding partner efforts have given very positive indications this could be duplicated across the health delivery
- 9. Situation Analysis continued… Figure 7.1: Households with Access to Safe Sanitation, Rural Areas, Zimbabwe 1992-2003 and 2015 MDG Target 2015 MDG Target -79% 48 56 58 42 90 80 70 60 50 40 30 20 10 0 1 992 1997 1999 2003 2 015 Year P e r c e n t Rate of progress required to achieve MDG Target Actual Source: Draft National Health Strategy 2008
- 10. Nutrition • The draft National Health Strategy document states that not much progress will be made in reducing illness and death, unless nutritional issues are considered as essential aspects of human well being • Prevalence of underweight has slightly increased to 17.4%. wasting at 4.1% and stunting at 28.9% • The nutritional patterns in the different parts of the country have tended to vary from district to district
- 11. Health Facilities Provinces Primary level 1st Referral level 2nd Referral level 3rd Referral level Total Harare 45 0 0 7 52 Manicaland 253 36 1 0 290 Mashonaland Central 130 13 1 0 144 Mashonaland East 168 22 1 0 191 Mashonaland West 128 22 1 0 151 Matebeleland North 92 17 0 0 109 Matebeleland South 105 18 1 0 124 MIDLANDS 106 28 1 0 235 Masvingo 170 23 1 0 194 Bulawayo 34 0 0 7 41 Total 1231 179 7 14 1431 Key Primary level = Clinics and Rural Health Centers 1st Referral level = District, Mission and Rural hospital 2nd Referral level = Provincial Hospital 3rd Referral level = Central hospital and infectious diseases hospital
- 12. Health Facilities continued • Health infrastructure capital investment has not kept pace with population expansion • Since the family Health Project financed by the World Bank in early 1990, there has been limited capital injection in the building of new facilities • The bed Occupancy Rate has increased to unmanageable positions for the hospitals to take on the burden of HIV • Lack of food in hospitals has resulted in in patients being referred for home based care
- 13. Human Resources Vacancy status: December 2007 Category Establish ment In Post 2005 % vacant Posts in Post 2006 % vacant Posts In Post 2007 % vacant Posts Top Management 74 10 86% 7 91% 14 81% Doctors 1761 695 61% 668 62% 667 62% Nurses 19338 13078 32% 13495 30% 14768 24% Environmental Health Department 2395 1217 49% 1293 46% 1220 49% Pharmacy 578 336 42% 338 42% 318 45% Radiography 459 140 69% 158 66% 154 66% Laboratory 631 293 54% 324 49% 320 49% Administration 5759 4950 14% 4960 14% 4960 14% Records and Information 416 335 19% 335 19% 335 19% Program Managers 34 8 76% 8 76% 8 76% Total for the whole Ministry of Health and Child Welfare 35668 23552 34% 24071 33% 25343 29% Source: Draft National Health Strategy 2008
- 14. Human Resources continued • The average vacancy rate of 81% among the senior positions in the MoHCW • The high vacancy rates of 73% is amongst consultants at central hospitals • More than 55%, 40% and 70% of respectively doctors, nurses and pharmacy technician posts are vacant • Rural areas health facilities are being manned by an average 50% of the required skilled staff
- 15. Medical Equipment and Laboratories • Zimbabwe used to have such medical equipment and laboratory services in the decentralized health delivery service • District hospitals had all the services that would meet the priority diseases in the country • There has seen a general deterioration of laboratory services where the tiered system has failed • This has resulted in patients seeking services from the private sector where the costs are unaffordable
- 16. Medical Equipment and Laboratories cont • Tests such as CD4, liver function and some related tests for screening patients before enrolment into the national ART programme continue to have logistical challenges • It should be noted that where there is external support, in districts supported by the Global Fund and the Expanded Support Programme, some new pieces of equipment have been procured
- 17. Stock Status of VEN Items from NatPharm 2222000000004444 2222000000005555 2222000000006666 2222000000007777 Vital 63% 72% 82% 42% Essential 21% 56% 62% 23% All drugs 41% 65% 68% 31% • Availability for the first half of 2008, shows a declining trend • There are no more medical and surgical items for a service to be delivered • ART commodities have been provided through the Global Fund, USG and the Expanded Support Programme and some NGOs
- 18. Beyond The Current Situation
- 19. National Health Strategy (2008) Summary of the Current Situation Level of Health • The HIV and AIDS epidemic and related TB epidemic and other opportunistic infections, are having a serious adverse impact on health. • The increasing frequency of epidemics (e.g. cholera, malaria) is contributing to high burden of disease. • Due to recurring droughts, malnutrition on the increase. • Though declining, infant mortality rate and maternal mortality ratio still unacceptably high. • Increasing level of non-communicable diseases • Increase of crude death rate. • The gap in the level of health between urban and rural areas is static or getting worse Health Services delivery • Increased workload and overcrowded facilities. • Shortage of staff/ inability to retain staff • Inadequate and if available obsolete essential medical equipment. • Poor maintenance of equipment and physical facilities. • Inadequate financial resources, especially foreign currency, which at least above inflation in real terms. • Inadequate mid level leadership due to continuous loss of key staff. • Shortage of in inputs such as fuel, vaccines, drugs, and transport in the public health services.
- 20. SWOT Analysis of the Health Sector of the Zimbabwe Health Sector Strengths • Commitment to have the highest possible level of health and quality of life for its citizens • Decentralized health system • Commitment to Primary Health Care approach • Public health network covering the whole country. • Clear health policies and guidelines. • Committed health professionals. • High health literacy. • Availability of Professional standards. • Demand for health services high Weaknesses • Inadequate skilled human resources across the board. • Low staff morale and high attrition rate • Poor remuneration packages and retention strategies. • Inadequate experienced managerial capacity at all levels • Core health services for each level not costed • Weak inter-ministerial coordination • Inadequate monitoring and evaluation of programmes
- 21. SWOT Analysis of the Health Sector of the Zimbabwe Health Sector continued.. Opportunities • Free health services for targeted population groups. • Parliamentarians interest in health issues • Introduction of Results Based Management • Incentive packages for some districts District Health Executive staff • A strong private health sector • Funding partners committed to funding health sector. • Globalisation encouraging exchange of ideas. Threats • High levels of attrition compromising quality of services • Unstable economic environment reducing resources to the health sector. • HIV/AIDS pandemic affecting all activities. • Poverty and food security • Drug resistance • New disease patterns
- 22. Support from Funding Partners • Strength in good relationship between funding partners and MoHCW • CDC and USAID have continued to support the country on HIV and AIDS issues and have provided support in training, equipment and reagents for the laboratory services
- 23. Priorities For The Funding Partners and the Health Sector • Arresting the brain drain through retention schemes • Revitalize the capacity of training facilities • Significantly increase funding to health services delivery • Strengthen expenditure management and budget planning • Continue with medical and surgical supplies
- 24. Short term Possibilities for the health delivery service • Human Resources Ministry has taken a more proactive stance on the issue of human resources as they have managed to make use of the resources in the Global Fund to improve on the human resources • Drugs and medicines The main funding partners in Zimbabwe have come together to form a basket funding for vital and essential medicines
- 25. Short term Possibilities for the health delivery service continued… • Health Information Systems Need to prioritized in the short term for the design and identification of the gaps and then with a good measure of resources be put in the long term activities for both donors and Ministry to work on
- 26. Information on Status of the infrastructure • There is no likely capital injection that will be used on infrastructural development • There is need to invest in collection of information on the state of the different infrastructure • This status information could best be collected by a neutral body such as the UN which might need to look at all basic infrastructure which will require capital injection
- 27. Medium to Long Term • Plan and fund the revitalization of training capacity • Health information system • Technical assistance in health planning • Revitalize systems and institutional arrangements for logistics for medical supplies • Rejuvenating communities demand for care • Health Infrastructure • Medical and surgical • Radio and communication
- 28. Conclusion • The major priorities in the short term are activities which will guarantee a minimum package for human resources for health, the policy, strategy, training and retention packages • Improvement of the medical supplies and thereafter the other issues can be considered in the medium to long term • Need to inject capital in the Health Delivery System as its key pillars are still in place