health delivery systems in the crisis and beyond

Health Delivery Systems in the

Crisis and Beyond

Presented By

Dr. T. Magure

MBCHB,MPH,MBA

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

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

Situation Analysis continued…

Estimated Crude Death Rates (CDR), Zimbabwe, 1980-2007

0

5

10

15

20

25

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

Year

CD

R (

per

100

0)

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)


• 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


Trends in the estimated adult (age 15 to 49 years) HIV and AIDS prevalence and incidence, Zimbabwe, 1980-2007

05

101520253035

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

Year

Per

cen

t

Adult prevalence Adult HIV Incidence

Source: Draft National Health Strategy 2008


• 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


Figure 7.1: Households with Access to Safe Sanitation, Rural Areas, Zimbabwe 1992-2003 and 2015 MDG Target

2015 MDG Target -79%

4856 58

42

0

10

20

30

40

50

60

70

80

90

1992

1997

1999

2003

2015Year

Per

cent

Rate of progress required to achieve MDG TargetActual


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

Health FacilitiesProvinces 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

KeyPrimary level = Clinics and Rural Health Centers1st Referral level = District, Mission and Rural hospital2nd Referral level = Provincial Hospital3rd Referral level = Central hospital and infectious diseases hospital

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

Human ResourcesVacancy 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%


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

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

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

Stock Status of VEN Items from

NatPharm

2004200420042004 2005200520052005 2006200620062006 2007200720072007

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

Beyond The Current Situation

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.

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

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

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

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

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

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

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

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

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

health delivery systems in the crisis and beyond

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