COMMUNITY Working Group on Health (CWGH) executive director Itai Rusike believes the country’s health system is in a state of decay. In order to solve the crisis, Rusike (IR) believes it is time that President Emmerson Mnangagwa re-visits his 2018 elections manifesto and fulfils his promises. Below are excerpts of Rusike (IR)’s interview with NewsDay (ND) Midlands reporter Brenna Matendere:
ND: Can you take us through the work that your organisation does?
IR: CWGH is a network of national membership-based civil society and community-based organisations that aim to collectively enhance community participation in health in Zimbabwe. It was formed in early 1998 to take up health issues of common concern and giving visibility to community processes on health in Zimbabwe. The organisation networks 35 national member organisations that represent various social groups across the country. The CWGH is currently operating in 40 districts of Zimbabwe. The CWGH network, in existence for more than twenty years now, has grown more informed and deeply rooted in the community and is now an important national people’s voice on health concerns. Over the years, it has positioned itself as a vocal advocate for equity, primary health care and public participation in health. These are all national policy goals, but have become increasingly marginalised by the market-driven economic reforms of the 1990s, exacerbated by the harsh economic environment of the new dispensation. The CWGH is a pressure point for public policy to reflect the health rights and social values that are widely held by the Zimbabwean populace
ND: Which areas have you covered so far and what is your broader vision?
IR: The CWGH has consistently engaged with stakeholders and the government to make primary health care (PHC) a more central policy principle, we have strengthened community participation structures such as health centre committees (HCCs) and boards and committees at district and national level to organise public efforts to achieve this principle. We support communities in their health literacy work and support their actions to revitalise PHC from the bottom up. People generally use public sector clinics as the primary source of health care, making it important for public and social accountability in the health delivery system. CWGH initiated a programme of work that enhanced information and networking on health issues at local level in 40 districts under our health literacy programme. We have been supporting community level meetings between health care providers and communities to promote and exchange dialogue at local level on promotion, prevention and management of health problems, and to strengthen informed participation in local health planning. The CWGH activities through HCCs aimed to shift participation in health from mobilisation for compliance with centrally defined programmes to mechanisms through which communities can shape their health systems and make services more responsive to their interests. Since 1998 the CWGH working with the Parliamentary Portfolio Committee on Health compiles a position paper on the health budget with input from our members and we present this paper to the Finance and the Health ministries as a way of community participation in the budget consultation process. Our broader vision is a society in which social justice and health rights are realised
ND: What is the state of the health system in Zimbabwe?
IR: Most of the health challenges facing Zimbabwe today emanate from the country’s deteriorating economy, which has seen the government falling to finance most of its financial obligations. There are acute shortages of basic medication, deteriorating patient care facilities in public health centres and disgruntled health personnel. We recognise that the current health crisis does not emanate from the health sector — it comes from wider economic collapse and the increasing extent to which people are not accessing basic public services like water, a major determinant of health. Many urban communities including Harare have gone for weeks and months without adequate water supply in a situation that has now declined over several years, leaving people vulnerable to diseases like COVID-19, cholera, typhoid and diarrhoeal diseases. Zimbabwe’s public sector health services have since independence been a buffer between people and the impoverishing and fatal impacts of ill-health caused by such conditions. The massive decline in our public health sector is thus a major crisis for poor people in the country, and leaves people starkly exposed to severe risk. The COVID-19 pandemic that the country and the international community is responding to has worsened our public health delivery situation in Zimbabwe. While this has obtained significant international attention, we are concerned that more chronic problems like maternal mortality, malaria and malnutrition are less obvious, but equally meriting of attention. People with chronic diseases like diabetes, cancer and hypertension are struggling to meet costs of their treatment. Such groups have difficulty taking medications when they do not have adequate food to eat.
ND: Some health experts say Mnangagwa’s administration has failed to deal with the problems in the sector?
IR: Now that the elections are over, the people of Zimbabwe expect the fulfilment of the election manifesto, in which Mnangagwa 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. For this reason, the CWGH would like to urge the government to immediately shift focus to real developmental issues, particularly taking into account the dire need of improving 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 Primary Health Care (PHC) system and addressing the social determinants of health to achieve Universal Health Coverage (UHC), thus enabling every Zimbabwean equitable access to essential quality health services without facing financial hardships. Presently, infrastructure in hospitals is dilapidated, some obsolete; medicines and supplies are in short supply; doctors, laboratorians, pharmacists, paramedics and nurses are inadequate and poorly motivated. And this against a background of sustained paltry funding to the sector from national fiscus is of major concern.
ND: Your take on citizens whose right to health has been violated through alleged abductions?
IR: We unreservedly condemn any acts of abduction and threat of physical assault. There is need to take decisive action against perpetrators of abductions and assault on citizens. Assault cases should be treated immediately with or without a police docket in the medical well-being of the victim.
ND: Zimbabwe has been on national lockdown since March 30, what are some of the health challenges brought about by the lockdown?
IR: We are concerned by the total disregard by those enforcing the lockdown of people’s right to essential services such as health, food and water. It has come to our attention that many people, some with chronic conditions, are failing to access their medications or missing critical appointments with their doctors because they cannot pass through the many police checkpoints mounted around the country without the required exemption letters. The current economic downturn characterised by the high cost of food prices as well as spiralling inflation has unfortunately worsened the situation especially for the vulnerable people in the country. Badly affected is the informal sector, which currently supports over 90% of the country’s 14 million people. In the absence of functioning national safety nets, many poor families, the disabled and the majority of the informal sector workers have already run out of food and other basic household needs during this three-month-long lockdown. They had little or no savings of their own.
The CWGH notes that human rights must be maintained in confronting COVID-19, without exception. The government of Zimbabwe as the duty bearer must take additional social protection measures to protect and support those disproportionately affected by the crisis, including the vulnerable groups, health workers and women who bear a heavy care burden and live with a heightened risk of gender-based violence. The health delivery system in Zimbabwe is being overwhelmed, with a lack of health care capacity for patients and a lack of personal protective equipment (PPE) for the frontline health workers.
ND: What can government do to address these problems?
IR: We ask for all the COVID-19 related funding and donations including expenditure and all procurements to be transparent, they should be subjected to public scrutiny, with mechanisms to prevent corruption and must be accountable to the citizens in order to maintain public trust. The COVID-19 funding should be used to surge and strengthen the public health delivery system including the training and recruitment of well-paid and well-protected health workers as well as the suspension of user fees at least for the period of the pandemic to ensure unconditional access to all health services for all free at the point of use. The government should consider channelling a portion of COVID-19 response funds to protect and bolster HIV, TB and malaria programme infrastructures, by strengthening health systems, supporting resilient supply and procurement systems, and facilitating a quick, and flexible response to stock outs of key commodities nationally. The response must apply the principles of universal health coverage (UHC) and multi-sectoral collaboration. This includes empowering and capacitating community and civil society partners to help deliver the response. COVID-19 is a national crisis of health, economic, social and political dimensions that requires a collective national response where we prioritise leaving no one behind.
ND: Strikes by doctors and nurses continue to cripple the health sector, what can be done to solve this problem?
IR: The Health Services Board must address the glaring management and governance issues and ensure that the employer of choice for all health workers is central government as obtained in the past. Managing a professional workforce requires skill and capacity that we find missing in the public health sector and this largely accounts for the mass exodus of our highly trained health workers to offer their young productive lives elsewhere.
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 than it currently is. However, all this can be achieved if the government increases national budgetary funding for the health sector, which also comes with fixing the current constipated economic fundamentals. The first and immediate steps in addressing the health workers needs are financial as the government should urgently address the real wage declines and improve real earnings. The new salary scales are best backed by a mix of incentives that address health workers’ concerns, including opportunities for professional development, meaningful career paths as well as improved working, living and social conditions. The government should also seriously consider pegging health workers salaries and conditions of service as per regional standards. It is worrying that strikes by health workers, including doctors and nurses have become so frequent in the country, at times three times in a year. It is unfortunate that previous dialogues between health workers and government over salary and better working conditions have not yielded concrete and long-lasting solutions because government has always reneged on promises, leaving the workers exposed. CWGH urges government to honour previous and future promises to health workers to build trust between dialoguing stakeholders. CWGH urges government to up the game in trying to address the plight of health workers to ensure they also afford decent food, rentals, clothing and school fees for their children.
ND: Some health workers said government shut out international aid agencies that wanted to pay doctors in foreign currency on the basis that other civil servants like the military would revolt. Your take?
IR: It is risky and unsustainable for a country to depend substantially to pay staff retention allowances on external partners as donors can withdraw financial support anytime should their interests shift for some reasons, it poses a national security threat should the external partners pull the plugs. Therefore, Zimbabwe needs to design and implement new and innovative domestic health financing policies to improve the conditions of services for the health workers.
We have over the years proffered several options and strategies that Zimbabwe can explore for innovative mobilisation of resources building on best practices in global health financing to boost public spending on health without undermining fiscal sustainability.
ND: How can Zimbabwe solve its broken health system?
IR: CWGH believes that addressing the country’s onerous health challenges requires total political commitment to implementing the primary health care concept to achieve universal health coverage to ensure that every Zimbabwean enjoys his/her right to health. The advent of the new Constitution means that government as the guarantor must commit to health as a human right and mobilise domestic resources to fund a health benefit that is accessible to all. Zimbabwe needs a renewed commitment to health and well-being for all based on UHC and should locate PHC as a necessary foundation to achieve UHC. Our focus is thus on UHC as the end and PHC as the means. We call for an economic order that would serve the attainment of health and reduce inequalities in health nationally, while also recognising that the promotion and protection of people’s health in both public and private sectors is essential for socio-economic development. We take this opportunity to remind President Mnangagwa that some Zimbabweans when ill still walk over 30km 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 10km 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.