PARLIAMENT SENSITISATION WORKSHOP REPORT. Training and Research Support Center (TARSC) Community Working Group on Health (CWGH) Parliament of Zimbabwe

Transcription

1 PARLIAMENT SENSITISATION WORKSHOP REPORT Training and Research Support Center (TARSC) Community Working Group on Health (CWGH) Parliament of Zimbabwe August 2009 Cresta Lodge, Harare; Zimbabwe With Support from Southern African Parliamentary Support Trust (SAPST) 1

2 Table of contents Executive Summary Background Opening and Introduction Presentations Primary health care and the social determinants of health Organization of Health services and Health worker issues Procurement and Supply of Equipment Health Financing and Budget issues HIV/AIDS Universal Access, Model HIV Law Health laws and constitutional protection for the right to health Traditional Medicines- Role in PHC Overview of health sector issues and trends Drug procurement Priority areas Closing Appendices Appendix 1: Delegates Programme Appendix 2: Participants List Cite this publication as: Training and Research Support Center (TARSC) Community Working Group on Health (CWGH) Parliament of Zimbabwe (2009) Parliament Sensitization Workshop Report, August 2009, TARSC.Harare 2

3 Executive Summary Success of the health system often depends on legislators, who play an invaluable role in conducting ongoing health system oversight and in guiding program improvements through a systems reform approach. The primary task of legislatures is to frame the structure and policy priorities of government through legislative and funding decisions. The legislative oversight role is critical to effective, ongoing government operations. Legislators have proved that they can play a key role in promoting health and health equity through their representative, legislative and oversight roles. There is potential of a focused, evidence-backed campaign in different areas of Health with effective involvement and participation of parliamentarians. Legislators provide an important mechanism for taking national policy issues to public and local debate and for local issues to be brought to national attention, if adequately supported to do so. This suggests that there is need to support legislators to raise very specific questions on priority health issues that they want executive action on, while using debates as a means of raising more general policy and public awareness on wider concerns. Legislators ensure actions that promote health, restore and maintain health are allocated the necessary financial resources and the legal environment is in place to support them To support this, Training and Research Support Centro (TARSC) and the Community Working Group on Health (CWGH) worked with Parliament of Zimbabwe, with the support of the Southern Africa Parliamentary Support Trust to hold a sensitization workshop for parliamentarians directly involved health. The Legislators included members from the Parliamentary Portfolio Committee on Health and the HIV/AIDS Thematic Committee. The meeting also brought together other stakeholders involved in health issues. This meeting showed that legislators are ready and keen to focus on pursuit of specific health issues, within a wider strategic plan, and follow these issues through a range of means available to them by virtue of their roles. It appears from the meeting that legislators can make progress on health outcomes by raising awareness of the issues through parliament debates, by raising public attention to prioritized concerns through media liaison, by gathering evidence and views from communities and communicating issues to communities through constituency visits, and by raising very specific questions to the executive to address. All of these roles and actions could thus be developed to advance a specific health goal, within the main framework. Ensuring that parliamentary processes are able to preferentially provide access to decision-making processes for the most vulnerable and poor is an essential component of a human rights approach to health. In addition, parliamentarians confirmed that the inclusion of the right to health in the new Zimbabwe Constitution was not just about individual claims but also about socio-economic entitlements for groups and for the community at large. Delegates agreed that casting health goals in a rights paradigm would add a greater urgency and level of accountability for delivery, once agreed on, as such the participation and push to see the right to health under the bill of rights in the new constitution was key and essential. The legislators observed the need to revitalize the Primary Heath care strategy through the provision of an essential health package for the primary care level while also defining and costing PHC. Delegates noted that priority should be given to ensure that the basic 3

4 level of provisioning is funded and universally delivered by all providers of primary care clinic services (central, local government, mission and other private) through budget, resource allocation and incentive mechanisms, monitored by communities, local government and health workers.). Further there was consensus on the need to have an HIV/AIDS law, using the SADC model law and experiences of other countries as references. In addition there was agreement that health funding should meet recommended targets of the Abuja Declaration in order to reduce out-of-pocket costs and reduce user fees that often hinder access and uptake of health services and information to communities. However, legislators noted that the National Health Insurance Scheme would further financially burden the small working population. Legislators identified priority areas for follow up at committee level as shown below: Priority areas for follow up. Enforce the guidelines for procurement and distribution of drugs (The buying and distribution of drugs and equipment be centralized to reduce the cost of procurement) Revitalize the Primary Heath care strategy (An essential health package for the primary care level and PHC be defined and costed. A priority be given to ensuring that this basic level of provisioning is funded and universally delivered by all providers of primary care clinic services (central, local government, mission and other private) through budget, resource allocation and incentive mechanisms, monitored by communities, local government and health workers.) An organized traditional health sector with support for national regulation and registration of herbal medicines is part of the comprehensive PHC system and needs to be further developed through clinical research. Protect intellectual property rights of traditional practitioners, and support proper registration of traditional practitioners Strengthen oversight function of legislature (e.g. NAC and NSSA should be made to account ) and revisit delegated legislation on health regulations and other (e.g. revisit the statutory instrument on the pensioner s fund) The right to health should be embedded in the new Zimbabwe Constitution under the bill of rights (An effective provision in the constitution should protect the underlying social determinants of health alongside the necessary access to medical care and freedom from physical interference). This should be supported by domesticating international Conventions, particularly the right to health (Article 12) in the International Convention on Economic and Social Rights. Lobby??/ grammar??for increased resources towards health with emphasis on the reduction of disease burden and prevention (this will entail addressing the major barriers in access and uptake of health services including Drugs, transport and costs) Decentralize chronic care (The chronic disease register be reintroduced to support access to chronic care management at primary care level;) Define a legal instrument that legally provides for the existence of Health Center Committees and supports community roles and participation in health Enforce the Code of Conduct for Health workers and enforce policies on ethics and support the Health Services Board by giving it greater decision making latitude on the health personnel and incentive measures needed for improved functioning of primary care workers including community level workers.) Clinics should be made cost centers (the MOHCW to revise its policy and decentralize its budget cost centers to primary care level (currently to district levelemphasis on equitable distribution of resources). 4

5 Redefine the role of media in health and skew it towards health education (e.g. criminalization of HIV+ who purposively infect others; on gays and lesbians, abstinence, condom use, faithfulness amongst other issues including PHC) Each committee agreed to priorities three key areas for follow up action. The action program would involve identification of what has been done on the issue and current impact, short term legislative goals, strategies and actions to be taken to achieve the goals, information/evidence gaps that need to be addressed and resources and stakeholders that can be drawn to support these actions. In closing Senator Khumalo, Chairman of the HIV/AIDS Thematic Committee reminded legislators to ensure that the right policies were in place for the realization of the health for all vision and towards attainment of Millennium Development Goals. 1. Background. The parliament sensitization meeting on health was targeted at the Health Portfolio committee in Parliament and the HIV/AIDS thematic Committee in Parliament to access the information they need to make informed decisions on health issues. The initiative brought together legislators in both committees and health experts to share information and to identify innovative solutions and enhance information sharing on critical health issues. Health policy is the result of bargaining processes of the actors (governments, medical and public health system, social movements, private sector and media etc.). Further success of health policies confronting the health system will depend on the ability of actors to understand and to accept the different approaches of all other actors, to incorporate priority needs into an integrated concept of health and health policy, and to broaden their scope towards a national vision of the priority needs. To support this, Training and Research Support Centro (TARSC) and the Community Working Group on Health (CWGH) worked with Parliament of Zimbabwe, with the support of the Southern Africa Parliamentary Support Trust to hold a sensitization workshop for parliamentarians directly involved health. The Legislators included members from the Parliamentary Portfolio Committee on Health and the HIV/AIDS Thematic Committee. The meeting brought together Members of Parliament and Senators from the Health Portfolio Committee and the HIV/AIDS thematic Committee, Non Governmental organizations, ZINATHA, Community Based Organisations, Academia, SAFAIDS, UN bodies and media. The full list of delegates and organizations represented is shown in Appendix 2. The meeting was aimed at presenting key health issues and having dialogue on pertinent needs in the health sector while also providing an opportunity for the new committee on health and theme committee on HIV/AIDS to review their plans in the light of information shared and identify priorities for follow up action. The meeting highlighted the current challenges in Primary Health care in Zimbabwe and proffered recommendations on how PHC could be revialitalised, promoted and strengthened. Further, it also gave an overview of the health sector trends, including in relation to the Millennium Development Goals (MDGs) and offered recommendations for legislators on several issues including in health services and health worker issues; in Health financing and budget issues; HIV and AIDS; Health laws and constitutional rights to health and in 5

6 the procurement and supply of drugs and equipment (See programme of the meeting appendix 1). The report has been compiled by TARSC. 2. Opening and Introduction Chairing the opening session, the former Minister of Health and Chairman of the Parliamentary Portfolio Committee on Health Dr Parirenyatwa acknowledged that the success of the health System often depends on legislators, who play an invaluable role in conducting ongoing health system oversight and in guiding program improvements through a systems reform approach. He highlighted that the primary task of legislatures is to frame the structure and policy priorities of government through legislative and funding decisions. The legislative oversight role, however, is critical to effective, ongoing government operations. He added that many legislators recognize that the health system, require policymakers sustained attention because poor health has lasting human and financial costs, and the consequences of failure can be tragic. As legislators know, a more proactive approach to governance requires their involvement in an ongoing reform process that is rooted in an objective assessment of government systems. He welcomed delegates to the workshop and noted that this was a platform for the new and old legislators to interact and share ideas on health related issues. He further acknowledged that Legislators in the national government sphere are engaged in the central political tasks of law making and policy formulation in a political system. They are responsible for the general welfare of the citizenry and should be constantly be aware of the real needs, desires and values of various communities. They must decide how to 6

7 allocate scarce resources (money, human resources and natural resources) and choose between the wishes of various constituencies when formulating policy. He observed that the Parliament sensitization meeting was offering an opportunity for the health legislators to know the current health issues in order for them to make informed decisions on health related concerns. He was grateful that the Training and Research Support Center (TARSC), the Community Working Group on Health (CWGH) with Parliament of Zimbabwe and with support from The Southern African Parliamentary Support Trust (SAPST) were hosting this meeting for legislators. He added that the platform would enable legislators to make informed decisions around health care needs. Engagement in decision making is likely to have a direct, positive effect on the non-expert participants, and involving the nonexpert public in deliberations about health sector developments as they take shape, rather than after the fact, may actually shorten the time and reduce the resources required to bring new ideas into service. Equally important, public participation may also result in design changes that better reflect the needs and desires of society. Informed decision-making is important for all citizens of a democracy and is vital for leaders in government and industry whose decisions influence the health and welfare of the nation. Legislators, who set policy and allocate resources, largely determine the national agenda in education, health care, and many other areas. Industry shapes the consumer culture and drives economic growth and productivity through investments in research, product development, and marketing. Government and industry both face a daunting array of issues. He noted that there is a great unmet need in both sectors for information and education that would contribute to more informed decision-making about revitalizing the health system in Zimbabwe. Dr Parirenyatwa invited the CWGH to outline the objectives of the workshop. Standing in for CWGH Executive Director, Mr. I Rusike; Mr. Tafadzwa Chigariro from CWGH outlined the objectives of the workshop. The meeting was aimed at presenting and having dialogue on information on key issues affecting the health sector and health while also providing an opportunity for the new committee on health and theme committee on AIDS to review their plans in the light of information shared and identify priorities for follow up action. The meeting specifically gave an insight on the following key issues: Organization of health services and health worker issues Primary health care and social determinants of health Health financing and budget issues HIV and AIDS and progress towards universal access Health laws and constitutional rights to health An overview of the health sector trends, including in relation to the MDGs Procurement and supply of drugs and equipment Mr Austin Zvoma, the Clerk of Parliament, gave the opening remarks. He observed that health matters were not only the domain of health experts, and members of parliament with no health background could do a lot on health issues. The constitution encapsulates the role of members of parliament, among them, supporting line ministries in delivering service. He further acknowledged that members of parliament were analogous to the biblical prophets only that they speak from the chambers. Parliamentarians thus need to ensure that health laws should be incorporated in the constitution of the betterment of the health of the people of Zimbabwe. 7

8 The recent development of the establishment of the thematic committee on HIV/AIDS in the senate shows parliament s responsiveness to constitutional obligations. Mr Zvoma added that the relationship between the parliamentary committees and the ministries has improved. Parliamentary committees were initially thought to be prosecuting the ministers, but now the two organs are now working together fruitfully and this relationship should be protected for the betterment of our country Mr Zvoma, Clerk of Parliament He was grateful for the efforts of TARSC, CWGH and SPST in teaming up and organizing the workshop to ensure that members of parliament were conscious of the challenges of the health sector, particularly shortage of drugs, primary health care and financing. He added that a national, publicly funded health care system would best serve the health of Zimbabweans while the success of the health system is critically dependent on sustaining the health workforce. In addition he highlighted that the principles of the Primary Health Care approach, offer the best framework for rebuilding the national health system. He implored the legislators to improve on what is already there, work towards enshrinement of health rights in the constitution and the adoption of best practices for health, i.e. the primary health care approach. Lastly, Mr Zvoma recognized the three organizers of the workshop- and hoped for a fruitful workshop that would yield good results. The Chair, Dr P.D Parirenyatwa noted that it was important that the workshop familiarized the new legislators with health priorities, which, in his opinion included: human resources, drugs and medicines, infrastructure and equipment, transport, financial resources and diseases burden particularly TB, HIV/AIDS, malaria including the non communicable diseases like diabetics and hypertension. Furthermore, he emphasized the need to look at the millennium development goals 4 (reduce child mortality), 5 (Improve maternal Health) and 6 (Combat HIV/AIDS Malaria and other diseases). He added that Millennium Development Goals are based on time-bound and measurable targets accompanied by indicators for monitoring progress and should not be viewed in isolation of other policies that influence the environments for health as they also affect the attainment of health goals, particularly poverty reduction. Dr Parirenyatwa highlighted that the liberalization of trade resulted in the introduction of user fees in the health system and it was important for the legislators to look at the implications in light of the gains that had been made during the adoption of the primary health care policy since The role of NAC in relation to affordability of health care also needed to be readdressed. There was need for the legislators to review the Public Health Act and how parliamentarians could lobby for improved HIV and AIDS drug accessibility. New developments in health, for instance the issue of male circumcision needed to be looked at from a legislative point of view. He reminded legislators of the need not to ignore traditional medicine, with some countries even having gone a step ahead in establishing ministries of traditional medicine, yet in Zimbabwe, traditional medicine is only a department in the Ministry of Health. He implored legislators to be vigilant and familiarize themselves with the patient charter, gather oral evidence on negligence in health institutions and strengthen partnerships with researchers and partners. Dr Parirenyatwa thanked the opening speaker wished that the discussions 8

9 would be fruitful and all delegates would participate fully and declared the workshop officially open. 3. Presentations 3.1 Primary health care and the social determinants of health Ms. F. Machingura (TARSC) presented the findings of the assessment of PHC in Zimbabwe implemented in March April by TARSC (R Loewenson, A Kadungure, C Maxwebo) and the CWGH (I Rusike, T Chigariro, A Makone) with teams of three people from each of the 20 districts of the CWGH. The exercise was a community based field assessment that gathered evidence but also built capacity at community level ot assess and advocate for PHC. She co-presented with Mr T.Chigariro from CWGH who gave an outline of the CWGH experiences and opportunities for acting on PHC issues at community level. Ms Fortunate Machingura noted that Primary health care (PHC) is a strategy that seeks to respond equitably, appropriately, and effectively to basic health needs and to address the underlying social, economic, and political causes of poor health, to provide accessible essential health services and to involve the participation of communities. Comprehensive PHC appears to be particularly suited to addressing the current challenges and health needs in Zimbabwe. It addresses the priority problems causing ill health, bringing resources for health to the individuals and families that most need them, it addresses health at its most cost effective level and taps a resource that communities have in abundance- people. Taking this forward calls for clearer information on the current situation with respect to the major elements of PHC, where the gaps are, and what potentials there are to revitalize PHC. To support this, TARSc and CWGH carried out a 1 The full Report- Training and Research Support Centre (TARSC) Community Working Group on Health (CWGH) (2009) Health where it matters most: An assessment of Primary Health Care in Zimbabwe March 2009 Report of a community based assessment: TARSC Harare; also at 9

10 situation assessment of PHC in Zimbabwe. The work built capacities for, implemented and reported on a cross sectional survey of primary health care conditions in sentinel wards in 20 districts of Zimbabwe in March The assessment signaled the potential for rebuilding Zimbabwe s health system from the bottom up. It presented issues and options from local level for wider discussion and input to the national PHC strategy. She added that the assessment included two stages of training that built capacity for personnel at community level to carry out the assessment, and to analyze and report on their findings and engage on the findings. In the twenty districts the assessment teams and CWGH committees had begun to follow up on the work, engaging with the health authorities in their areas on the findings. A national meeting was held with stakeholders in July 2009 to review the findings and the feedback from this had been sent to all stakeholders to begin follow up on the recommendations 2. The PHC assessment was aimed at assessing the primary health care conditions in 20 districts while also equipping primary care level CWGH personnel with skills to assess PHC in their wards.it aimed at using the evidence to support local and national dialogue on priorities for strengthening PHC. She outlined the methods, involving 540 household questionnaires, 53 monitor reports (observational data) and 71 key informant interviews from health facilities at primary care level, and highlighted the presentation was done on behalf of all those who were involved in the assessment at TARSC and the CWGH district personnel. The assessment covered different dimensions of PHC, including: Health education and health promotion Promotion of food safety and nutrition Safe water, sanitation and waste disposal Maternal and child health and immunisation Essential health services Community participation and Perceived priorities at local level Radio ownership was found to be high although barriers to use included shortage of batteries, signal and electricity. Cellphones were also common and there was room to tap these as assets for health for instance in e-health. Communities were facing transport constraints, both in terms of availability and cost. Machingura summarized the key findings under the PHC dimensions mentioned above. Health education and promotion, while there were relatively high levels of basic health knowledge in Zimbabwe, there was inadequate specific knowledge to inform effective action. For instance, although 93% of the households had heard about ORS, 53-68% knew the correct amount of salt and sugar used in the preparation of SSS. Households were also found to be having gaps in materials for PHC, with only 61% of the households reporting having the sugar to make SSS. These knowledge gaps called for regular promotion of health literacy supported by community cadres- VHW and EHTs. Households were also reported to be struggling with the cost of health, with the basket of items required for health for an average family of 4.2 being reported to be at USD271.58, a 65% increase from the March 2005 figure (using official rate) and 280% 2 Training and Research Support Centre (TARSC) Community Working Group on Health (CWGH) (2009) Stakeholder Review Meeting on the Community Assessment for Strengthening Primary Health care in Zimbabwe July 2009 Report of a Review meeting: TARSC CBRT, CWGH Harare. Also available at 10

11 increase (using the parallel rate). The proportion of health care items increased since 2005 while public health items, food items and hygiene items remained constant or decreased. Mr. Chigariro gave the impetus that communities can a lot to enhance PHC. For instance, TARSC and CWGH, through its health literacy programs had done promotion activities for instance cholera and malaria campaigns as well as HIV/AIDS and STI education. Communities had the capacity to act on identified priorities from their own areas. Food safety and nutrition, Ms Machingura reported that, from the assessment, most children had health cards and growth monitoring was being implemented. However, few communities had nutrition gardens to supplement nutrition of vulnerable groups, except for few that exhibited innovative practices where local business supplied seeds, water and fertilizer and the locals labour to set up the gardens. Low access to support for chronic problems at primary level was reported, e.g. diabetics thus the need to decentralize these services. Mr.Chigariro added that communities needed to know the right food quality and quantity and had the capacity to organize themselves to set up nutritional gardens, for instance in Chikwaka, where nutrition gardens were benefiting various social groups including pregnant mothers, health workers and children Safe water, sanitation and waste disposal. Ms. Machingura further highlighted that at 84% and 89%, safe water and sanitation, according to the assessment was encouraging. However, there is need to go beyond access and monitor functioning of the infrastructure. 16% of the households reported throwing garbage outside the yard. Urban areas had higher Diarrhoeal diseases that the rural areas, hence the need to readdress at PHC approaches in urban environmental health. Households in urban areas queried whether funds being paid for water and sanitation were not being diverted to other areas. On community actions at local Level, Mr Chigariro noted that the CWGH had been involved in clean up campaigns in various communities across Zimbabwe. Communities in Mutare, for instance, had formed watchdogs to monitor dumping of waste in open areas. He however emphasized the need for educating the communities and acknowledged that communities have shown the ability to mobilize resources and construct, for instance, blair toilets (CWGH Chiwundura) Maternal and child health. Ms Machingura noted that access to ANC, PMTCT, and assisted deliveries was reasonable- above 65% but many households were still delivering outside their districts, possibility due to cost. Only a few clinics had waiting mother shelters. Many households (66%) still thought it was not necessary to have birth 11

12 attended by a skilled health worker and cost and transport was cited as the other major barrier to assisted deliveries. Cost of treatment, distance and drug availability were cited as the major factors influencing choice of treatment for children. Thus, there is scope of improving access by improving drugs and enforcing free care policies. Supporting this, Mr. Chigariro noted the importance of health literacy and stated that communities can participate in mobilizing children for immunisation and construction of Waiting Mother s Shelters. Prevention and treatment of common diseases. Ms Machingura highlighted that Environmental Health Technicians (EHTs) numbers were generally low and very little (13%) malaria spraying was reported. Malaria drugs were relatively available (85% of facilities) and 65% of the facilities were implementing DOTS TB case tracing. 80% of the facilities had refrigeration for cold chain. VHW coverage was also reported to be very low (46% of the wards). The assessment thus raised the need for resource decentralization to clinics and support for community level outreach cadres and activities from clinics. Transport, cost and stigma were cited as major barriers to uptake of Voluntary Counseling and Testing (VCT) and antiretroviral Therapy (ART) and there is scope to improve access through decentralization and improvement in drug supplies. Most facilities had drugs for treatment of malaria, antibiotics for both children and adults and cholera treatment drugs but insulin for diabetics was relatively very low and absent in most districts. Mr. Chigariro pointed out the role of community level personnel, including the Village Health Workers. During the health workers strikes, these cadres continued to work to ensure that the health system does not completely collapse hence the need to recognize and provide incentives to these cadres. Community Participation: Ms. Machingura noted that only a few clinics had Health Center Committees (HCCs), while those that had them, they seemed inactive. There was a correlation between clinics with HCCs and households stating greater satisfaction from the clinic. HCCs do not have a legal framework yet they are vital mechanisms for community involvement in planning and decision making in health. She therefore implored the need to revive and resource these mechanisms and create a good environment for them to operate. Mr Chigariro noted that through active HCCs, the community in Nyava had organized resources to construct a house for the local nurse- a from of community efforts to retain health workers. Thus, HCCs improve relations between the community and health workers Ms. Machingura noted that the households, monitors and facilities had shared priorities but also did see things differently. For example while communities were more concerned with cost issues, health workers were concerned about their remuneration and the resources to function. The list of the priorities is shown below: Households Health education 12

13 Water supplies, sanitation, transport, disease control Drug supplies and health staffing Reduce charges at services Monitors Health literacy Water supplies, sanitation, sewage, malaria control Drug supplies, infrastructures, service quality Facilities Water supplies, sanitation, electricity, transport Drug supplies, infrastructures, pay, qualified staff Communication resources To summarize and conclude the presentation, Ms Machingura presented the reports conclusion that households were often disconnected from health workers with limited support for community and health outreach workers, variable HCC activity and limited resources at clinics to support community roles or provide frontline services. Households having to travel to further services not only spend more, but also lack the continuity of support for prevention and care that closer services can provide there was hope for a different approach. A different approach to health care, where health is in the community, i.e. decentralized services with immediate support from expert patients, households and community networks with the referral and other services supporting these mechanisms as shown in the diagram below is argued by the authors to bear fruit in both the short and the long term. She advocated for a comprehensive PHC approach that would strengthen the health system by putting people as key actors in the inner core of the system, strengthening accessible presence of health workers at the community and clinic level backed by adequate resources for key services like MCH and chronic care. She further observed that this approach would be able to address the current health challenges in Zimbabwe recognizing that there are important areas of progress and action around the PHC 13

14 strategy, however with the current implementation of PHC facing a number of constraints but also with potential to pick up and revitalize the Health system In plenary, delegates encouraged the enhancement of health promotion interventions that better prepare the citizens for any public health hazard. There is an urgent need to prioritize environmental health in urban areas especially amongst the vulnerable urban populace. Noting the difficulties surrounding the organization of the urban population to access health services, delegates recognized that decentralization efforts often impact legal and regulatory frameworks, making it necessary to clarify who is responsible for what services, and sometimes provide institutional and managerial capacity building for newly empowered service delivery agencies. Delegates acknowledged that working with the private and corporate sectors is a sensible urban strategy since these sectors often are already key service providers for the urban society. They may require service quality upgrading and other inputs to strengthen their capacity. Furthermore working with NGOs and CBOs is logical since they are often the strategic service providers in poor urban areas. They may need organizational, technical, managerial or other capacity building. They can form networks or consortia and coordinate efforts for maximum coverage and impact. Delegates further added that facilitating access to existing health services can be accomplished by addressing existing barriers. There was a general consensus that investment should be made around health education and health promotion strategies as they lower the cost of health in the long term. Legislators added that health education has shown that it lowers mortality rates and levels of morbidities. Further, it was emphasized that communities should be involved in the selection of village health workers for training by the ministry. Non- Financial incentives should also target the EHTs not just the Doctors and the nurses. Legislators agreed to create a platform that enables government to publicly fund the national Health system. 14

15 Delegates added that the assessment was done at a critical time and identified problems in the implementation of primary health care at the district level right up to key priority areas for legislators to seek sustainable solutions. Legislators agreed that to meet these challenges, the community must be empowered for participation; management and organizational development must take place at the district level; and national goals must be set and decisions made on how to decentralize authority and provide equity in resource distribution. Legislators noted the need for district health services to support the health information system, a separate financing channel from referral and academic health care providers, a personnel mix based on pattern of disease and effectiveness, cost, and feasibility of using members of each category of health personnel. 3.2 Organization of Health services and Health worker issues Dr.Lovemore Mbengeranwa, Chairman of the Zimbabwe Health Services Board, presented this session. In his introductory remarks, Dr Mbengeranwa spelt out the national vision for health, to have the highest level of health and quality of life to all the citizens of Zimbabwe attained through the combined efforts of individuals, communities, organizations and the government and which allow them to participate fully in the socio economic development of the country. The vision would be attained through guaranteeing every Zimbabwean access to comprehensive and effective Health Services. He noted that thee unmistakable imperative is to strengthen the workforce so that health systems can tackle crippling diseases and achieve national and global health goals. A strong human infrastructure is fundamental to closing today s gap between health promise and health reality, and anticipating the health challenges of today. Dr Mbengeranwa outlined the national health policy framework, stating that since 1980, based on the economic concept of growth with equity, Zimbabwe adopted the concept of planning for equity in health, a primary health care approach to the health system. Since early 1990, in the context of civil service reform and economic structural adjustment (ESAP), the MoHCW reformed the health services. The recommendations of the Presidential Review Commission of 1997 (adopted by government in 1999), which gave birth to the formation of the HSB continue to influence the content, context and pace of the Ministry of Health reform agenda. Health care providers in Zimbabwe 15

16 include the public health sector, the private sector and missions, and other nongovernmental organizations. Presenting on the legal framework governing health, Dr Mbengeranwa reiterated the need for education on the code of conduct for health care practitioners. The code of professional conduct for all health practitioners in Zimbabwe is regulated by the Health Professions Act Chapter 27:19 (2000). The Traditional Practitioners Act 1981 provides a framework for practice and regulation of its members while the Medical Services Act (1998) provides for the establishment and operation of both public and private hospitals and Medical Aid Societies. The Medical Services Act also provides for the establishment of Hospital Management Boards at Central and Provincial Hospitals while the minimum standards of practice for both hospitals and medical aid societies are also provided under the act. He proceeded to outline the structure and functions of the ministry of health and noted that the ministry operates within the framework of functions mandated to the office of the Minister of Health and Child Welfare as well as the Public Health Act (Chapter 15:09) These functions include the service functions of preventive, curative, health and management systems, laboratory services and safe supply of blood. He outlined the organization of the MoHCW from rural health centers, district hospitals, provincial hospitals, and central hospitals. He explained that the public sector consists of local authorities (rural district councils and urban local authorities) while other providers include the defence forces, prison services and the police. The private-for- profit sector consists of private hospitals, general practitioners, private maternity homes, and traditional health practitioners. Some in the private sector are not for profit; these include medical missions and NGO run services Dr Mbengeranwa s presentation on the HSB dwelt on the provisions of the Health Service Act (Chapter 15:16) and he outlined the functions of the board, board membership, delegation of the functions by the board, policy directions to the board, constitution of the health service, responsibility of the administration of the health service, appointments, promotions and dismissals and conditions of service of members of the health service as shown in the box below. Functions of the HSB To appoint persons to offices, post and grads in the Health Service; To create grades in the Health Service and fix conditions of service for its members; To supervise and monitor health policy planning and public health ; To inquire into and deal with complaints made by members of the Health Service; To supervise, advise and monitor the technical performance of hospital management board and State aided hospitals. To set financial objectives and the framework for hospitals management boards and State-Aided hospitals Handle appeals in relation to disciplinary powers exercised by hospital management boards over members of the health Service employed in any Government Hospital; To assist in resource mobilisation for the health service; To exercise any other functions that may be imposed or conferred upon the Board in terms of this Act or any other enactment. 16

17 Dr Mbengeranwa noted that thee migration of health care workers is not a new experience, the challenges have been more pronounced in recent years with increased out migration of the health workforce due to both financial and non financial incentives accompanied by the economic decline at a macro economic level in Zimbabwe. He added that developed nations possess the means to provide health workers with better pay, improved working conditions as well as opportunities for skills training and professional development, while Zimbabwe continues to struggle developing from outflows of human resources for health and failing to offer decent non financial incentives to its key human resources for health. This not only deprives the nation from skills, services, and functional referral systems, but also creates an economic loss in returns from investment, stagnating development. He further acknowledged that the brain drain has further depleted resource-pools of supervisors, health researchers, mentors, role models, as well as employment opportunities in spin-off sectors arising from the presence of paid professionals operating in clinical or office environments. Summarizing the key challenges facing the Health services board to address some of the challenges facing health workers, Dr Mbengeranwa noted the following:. Challenges facing the HSB High attrition rate of qualified staff attributable to poor working conditions and working environments and the economic environment. Salaries and allowances for health workers have remained low compared to the region Lack of affordable and decent accommodation for health professionals Lack of or non affordability of basic needs- water supply, sanitation and electricity Lack of adequate transport and communication Poor working environment owing to bad infrastructure, lack of equipment and drugs Lack of lecturers and materials to train future professionals He noted that there is need to make the MoHCW structures more responsive while also speeding up decentralisation in the MoHCW. In his concluding remarks, Dr Mbengeranwa highlighted the need to pay competitive wages to health workers to retain them, create a conducive working environment and improve transport and accommodation. He reiterated that his presentation was aimed at sensitizing the policy makers to avail resources for use in the attainment of the health vision. There is need for 17

18 other sectors to participate for instance the community and private sector may provide accommodation to health workers and free transport may be afforded to VHWs. In plenary, delegates agreed on the need to emphasize ethics to health practitioners. The need to have separation of power within the Hospital Management Boards was also highlighted and that it was not ideal for the hospital CEO to be the chair of the hospital management board. Delegates concurred that the HSB had no powers, it only recommends to the Minister of Finance through the Minister of Health hence there is need to make it autonomous. The HSB is now putting an emphasis on non-pecuniary incentives and communities and private sector should also join in to make this possible. There is a general feeling among health workers that they are not being taken seriously, we need urgent interventions that will address some of their priority needs to address attrition challenges and to meet goal and vision of health for all Dr.L Mbengeranwa, Chairman of the Zimbabwe Health Services Board 3.3 Procurement and Supply of Equipment Mr. Nhlanhla Masuku- Director, USK International, made a presentation on procurement and supply of medical equipment. In his presentation he argued that medical equipment is central in a health delivery system. He observed that most medical equipment is not functioning, not used correctly, and invariably not maintained, with serious consequences for patient care. This may be because the equipment often lies idle for want of a spare part. It is vital that a medical device management policy exists that includes a financial provision for maintenance, spare parts and training in the initial cost of the equipment. He further outlined the procurement process, noting that it includes identification of specifications based on generic, functionality based on user input, followed by the procurement cycle. The procurement cycle involves the soliciting of quotations that can be either from a sole supplier or many suppliers (3 quotations ideal) using an informal, formal or international tender process. After the successful tender is identified a predelivery inspection of the equipment by own staff, consultants or both is conducted. The supply element involves such issues as logistics, suitable packaging, transportation, documentation and storage. Issues relating to installation (usually supplier s responsibility), user training, handover and recording of the equipment in asset registers are also critical. Mr Masuku highlighted the benefits and drawbacks of a centralized procurement system and gave examples (for instance CMED, Medical stores, State Procurement Board) where this has been applied at national level. Effective logistical systems determine the success or failure of any health program. Decentralization and other health sector reform innovations, such as integration, cost recovery, and privatization, may affect logistics systems. He noted that when looking specifically at decentralization as a component of health sector reform in procurement of equipment, it is important to consider how it will affect the various functions of the logistics cycle. He added that centralizing the procurement process would eliminate intermediate levels in the supply chain because each level adds delays, excess inventory, possibility of supply imbalances, and costs. Each level also adds management challenges because the distribution system typically follows the political structure, which may not have been established with transportation efficiency in mind. He noted the recent shift to a decentralized procurement process in recent years. Adding to this, he argued that when 18

19 planning for decentralization, it is vital to first consider centralizing logistics system functions. This would be complemented by other centralized health system functions, such as drug registration, development of standard treatment guidelines, and health professional licensing Mr. Masuku implored the need to consider seriously the post supply interventions, emphasizing the importance of a maintenance culture in all establishments that procure and use equipment to minimize the downtime of equipment. Maintenance involves timely and regular checking and repairing of equipment, making use of trained engineers and technicians and spare parts. In addition, he noted that regular user training and refresher courses for maintenance personnel are essential. He advocated for the maintenance of specialized equipment (e.g. X-rays) through service contracts with suppliers. He drew the parliamentarians attention to the need to allocate resources towards maintenance of equipment as well. The maintenance function is an equally important element of the procurement function Mr Nhlanhla Masuku- Director, USK International In plenary, legislators explored the need to have legislation that ensures oversight on government equipment. This was after a realization that most government equipment is being abused. Legislators concurred on the need to have attitude changes towards government equipment and work together irrespective of differences in political persuasions to curb the rampant abuse of government equipment. The legislators further agreed that the health system should retain central capability for the logistics functions that will fail if decentralized. Key was to retain centrally on specification and enforcement of the essential drugs list; on product selection and essential service package specification; on bulk purchasing; on the rationing for scarce essential products; on ascertaining quality for all products and for logistics management information systems. While decentralization is popular and has its benefits, legislators agreed that it was key to consider decentralization of equipment and decision making only if local authorities and mangers had the resources to execute those decisions. 3.4 Health Financing and Budget issues Mr. Shepherd Shamu (TARSC), presented this session. He began by noting the current situation characterized by, among other things; decline in per capita expenditure, decline in real health expenditures, increase in private (especially out of pocket) expenditures, deteriorating primary care infrastructure, hospital based and urban oriented health care expenditure, low salaries, staff shortages and brain drain. Mr. Shamu discussed the elements of health financing noting resource mobilization, resource expenditure and resource monitoring. He identified the principal financing mechanism, which include tax based, private health insurance, social health insurance, donor financing, community financing, user fees and public/private partnerships. He noted that the bulk of government revenue comes from taxes and there was need to earmark some of the taxes (say excise on tobacco and alcohol) to meet specific health expenditures, for instance TB control. He implored the need to revisit some of the tax legislation for instance; medical contributions are tax deductible on the part of the employer, up to a certain level. 19

20 On private insurance, Mr. Shamu advised that they is a growing view that Health Care Funders are failing to provide comprehensive benefits because they are now concentrating on non-core activities such as building hospitals, establishing clinics, laboratories, pharmacies, and investing in financial institutions. He further noted that current preferential tax regime favors high-income groups. On donor funding of health expenditure, Mr. Shamu highlighted the need to consider such issues like sustainability, predictability and coordination and advocated for basket funding rather than segmented donor health funding. Further, he also noted the need for proper analysis before public health systems can consider public private partnerships and the extent to which these partnerships should be done, the beneficiaries and any resultant cross subsidies. He gave the example of the haemodialysis machines installed at Parirenyatwa hospital which are offering services beyond the reach of many patients. Presenting on user fees as a mechanism of financing health care, Mr Shamu noted that user fees have been acting as a barrier to accessing health care. A research on access to health care carried out in 2008 revealed that 38% of the respondents felt they should pay user fees. With a standard basket of items required for health for an average family of 4.2 standing at USD272 3, households appear to be already financially burdened. The primary health care assessment also revealed that cost was one of the major barriers affecting access to antiretroviral therapy as well as a major factor affecting choice of treatment for both children and adults. The increase in out of pocket expenditure continued to impoverish households as cases of selling assets to finance health were reported. The last section of Mr. Shamu s presentation was on the budget process, budget actors (main actors being the parliament, executive and judiciary) and important elements in budgeting. He thus explored the role of parliament in setting the policy direction regarding sources of financing health, resource allocation (equitable methodology) and resource mobilization mechanisms. The main issues arising from Mr. Shamu s presentation are shown in the table below Important Health Financing issues There is need for Increased budget shares for primary and preventive care and government spending on health should be at least 15% of national budget (Abuja commitment) Abiding by local and International estimates of funds needed to meet basic health goals or deliver a reasonable minimum of services: Essential package ranges from US$22 (World Bank) per capita to US$40 (WHO) per capita, with an estimate of $169 per capita when including costs of ARVs. Revisit the resource allocation formula and move away from the hospital based funding mechanism while also strengthening the management of hospital expenditures Move with caution when it comes to investment in the private health sector Reconsider reducing user fees as they limit access, user fees have not shown an ability to accumulate revenue. 3 Training and Research Support Centre (TARSC) Community Working Group on Health (CWGH) (2009) Health where it matters most: An assessment of Primary Health Care in Zimbabwe March 2009 Report of a community based assessment: TARSC Harare 20

21 A consistent motoring mechanism should be put in place and government should participate more in health. In plenary legislators concurred that there is need to relook at current taxation framework that is pro-corporate. Companies deduct their expenses before paying tax but individuals don t. Pension funds, in particular the National Social Security Act as well as National Aids Council needs review to align their priorities to the changing health needs. It was noted that access to ARVs is cumbersome, with patients going for months before they undergo their CD4 count testing, which they also pay for. Further, the HIV patients are still being asked to pay consultation fees each time they access their drugs. The need for basket funding of health by donors was also noted. With 10% of the economically active population in formal employment, it was felt that the introduction of the National Health Insurance Scheme would further financially burden the few, working in the formal sector. 3.5 HIV/AIDS Universal Access, Model HIV Law Mr. F Dube and Mr. O Mundida from the National Aids Council presented on the Universal access to ART in relation to the National Aids Council s plans. Mr. Mundida noted that the Zimbabwe National HIV and AIDS Strategic Plan (ZNASP ), notes that full coverage of HIV and AIDS services by 2010 may be unrealistic given resource constraints. Thus, the strategy aims at scaling up services to come as close as possible to universal access, with a minimum ART coverage of 75% in adults and 100% in children by The concept of universal access has now been explained to include prevention (UN General Assembly Special Session on HIV/AIDS, June 2006) and other HIV/AIDS services (treatment and care). Steps taken towards universal access include the following: ANC services (1628 facilities), 56 of these offer onsite CD4 count, 900 offer PMTCT and VCT, 55% offer PMTCT,VCT and ART 104 sites offer pediatric ART 1560 health facilities (95% of all sites) offer VCT Ministry of Health now offering PITC Provider Initiated Testing and Counseling Expanded condom distribution (both male and female) Behavior change campaigns Community home based care programs have also been scaled up, with a total of 162,300 patients on CHBC countrywide The Expanded Support Program, Global Fund and American government have provided resources towards scaling up ART (ARVs, vehicles, management and human resources) Mr. Mundida observed the following as obstacles to achievement of universal access Obstacles to Universal Access Inflation over the past 4 years eroded value of AIDS Levy AIDS Levy, although improving since dollarization, is still significantly lower than demand High dependency on external funds Limited donor funds in Zimbabwe Human resource (staff motivation; skills flight) Lab Capacity (CD4, lab consumables; supply chain system :equipment for tests) Drug prices 21

22 He argued that the required actions should focus more on increased domestic resource mobilization accompanied by regional and centralized bulk purchasing (ARVs). He further added that it was critical to invest in accelerated research in traditional medicine and harmonize medicine taxation laws On the same discussion Hon T. Khumalo presented on the Model SADC law on HIV and AIDS. She pointed out that most SADC countries are adopting specific laws on HIV/AIDS and it was important for legislators to consider similar approaches for Zimbabwe. Further, she pointed out some fundamental policy issues that require an urgent address by the legislators. These include the exclusion of PLWHA from civil service; compulsory testing and Criminalization of HIV/AIDS. She added that, SADC PF s committee finalized a model law on HIV/AIDS to provide specific guidance on HIV related legislation for countries that are adopting or have already adopted HIV- specific laws. The principles enshrined in the model law are perhaps captured in the preamble, which reads: Recognising the importance of a human rights-based and gender-sensitive approach, and the involvement of people living with HIV, in adopting effective legislation the model legislation builds on best practices in the region and elsewhere Hon T. Khumalo Honorable Thabitha Khumalo from the HIV/AIDS thematic Committee in Parliament further observed that the issues in the model law include: HIV and AIDS-related information, education and communication Non-discrimination HIV testing and counseling, disclosure and partner notification Rights of people living with HIV/AIDS Children, women and girls Vulnerable groups: Prisoners, MSM, IDUs, CSW, refugees, indigenous and mobile population. Treatment and care Supporting Honorable Khumalo s presentation, Ms. Monika Mandiki (SAfAIDS) gave an outline of how the Southern Africa Information Dissemination Service (SAfAIDS) has been working in the region around HIV/AIDS related issues. She highlighted the various efforts SAFAIDS has been contributing in the region, among them, - Production and dissemination of appropriate HIV information to political and civil society leadership - Promote a vehicle for sharing and disseminating HIV and TB related policies and information (Regional and National discussion platforms) - Promote the translation of policy into practice by creating platforms for debate and dialogue between civil society and political leaders (policy dialogue e.g. on ART) - Capacity development- Training for Networks of People Living with HIV As had been captured by previous presenters, she noted the various challenges to treatment advocacy, among them, consultation fees, distance, staff shortages, ARV shortages, food shortages, lack of machinery, staff attitudes, brain drain, poor 22

23 communication of programs to PLWHIV and migration of people on treatment, which makes monitoring a huge challenge. In plenary, legislators concurred with the PHC approach to managing HIV/AIDS treatment. The need to domesticate laws, and enact an HIV/AIDS specific law was cited as priority areas. Further, it was noted that there is need to allocate resources towards CD4 count machines to improve access to HIV/AIDS services. On the issue of compulsory testing, it was felt that it violates a person s rights thus the need to increase knowledge to improve on VCT. There were calls for increased efforts in the development of generic drugs for universal access to treatment. Increase community participation in NAC structures, improve ARV drug supply, and give incentives to Home Based Care givers. There was emphasis on the need for non-politicization of resources earmarked to fight HIV/AIDS while also managing AIDS holistically by addressing the underlying economic, political, social and cultural factors. 3.6 Health laws and constitutional protection for the right to health Presenting on this topic, Ms. Primrose. Matambanadzo, Director of the Zimbabwe Association of Doctors for Human Rights defined the concept of the right to health, noting that it is not limited to health care, but takes cognizance of the determinants of health and includes both physical and mental health. She noted that the concept looks at accountability, availability, accessibility, acceptability and quality of services and ensures that resources are equitably distributed to people. Ms P. Matambanadzo observed that the 1948 Universal Declaration of Human Rights mentioned health as part of the right to an adequate standard of living The right to health was again recognized as a human right in the 1966 International Covenant on Economic, Social and Cultural Rights. She added that since then, other international human rights treaties have recognized or referred to the right to health or to elements of it, such as the right to medical care. The right to health is relevant to Zimbabwe, as it has ratified at least one international human rights treaty recognizing the right to health. Moreover, Zimbabwe has committed to protecting this right through international declarations, domestic legislation and policies, and at international conferences. She further implored the need for legal protection of the health rights, protection of individual and groups and obligations of the state (respect, protect and fulfill). She noted the need for non-discrimination when accessing health services, provision of all vital drugs and equitable distribution of resources as well as the responsibilities of the community. She added that, individuals right to health cannot be realized without realizing their other rights, the violations of which are at the root of poverty, such as the rights to work, food, housing and education, and the principle of non-discrimination. She noted that discrimination means any distinction, exclusion or restriction made on the basis of various grounds which has the effect or purpose of impairing or nullifying the recognition, enjoyment or exercise of human rights and fundamental freedoms. It is linked to the marginalization of specific population groups and is generally at the root of fundamental structural inequalities in society. This, in turn, may make these groups more vulnerable to poverty and ill health. Not surprisingly, traditionally discriminated and marginalized groups often bear a disproportionate share of health problems. She observed that, overall; there should be progressive realization of the health rights with 23

24 time. She explored the possibilities of protecting the health rights in the constitution through the bill of rights and adopt a rights based approach to health laws. She added that the Right to health should be embedded in the new Zimbabwe Constitution. Noting that the state has the primary obligation to protect and promote human rights that are defined and guaranteed by international customary law and international human rights treaties that in turn create binding obligations on the countries that have ratified them to give effect to these rights within their jurisdictions. She argued that the state should, at a minimum, adopt a national strategy to ensure to all the enjoyment of the right to health, based on human rights principles that define the objectives of that strategy. Setting indicators and benchmarks will be decisive in the formulation and implementation of such a strategy. Indeed, the right to health being subject to progressive realization, what is expected of Zimbabwe will have to discussed and agreed thereupon. She added that there would be need to monitor and measure variable dimensions of the right to health once it is set in under the bill of rights in the new Zimbabwe constitution. In plenary, legislators concurred that Zimbabwe should look for a suitable mechanism of protecting health rights by learning from the experiences of other countries. There was call for institutional mechanisms to monitor performance and distribution of power in communities. The constitution should provide the broader framework for the protection of the health rights. 3.7 Traditional Medicines- Role in PHC Ms F Chiguvare Office of Traditional Medicine in the MoHCW and Dr C.C Maponga- University of Zimbabwe College of Health Sciences presented on the role of traditional medicine in primary health care. There is need of integration of traditional medicines into primary health care strategies through collaboration, communication, harmonization and partnership building between the clinical system and the parallel traditional medicine system. However it is essential and key to insure that property rights and protection of indigenous knowledge is achieved. They noted that while traditional practitioners refer patients to modern practitioners, the reverse is no true and legislators should work with the ministry of health to enable such integration to take place. The MoHCW has established An independent department specifically for traditional medicine to coordinate traditional medicine activities, oversee issues of policy, research and development as well as collating data for evidences based research and policy shaping. They further highlighted the need to accelerate strengthening of traditional medicine trough training and policy frameworks. Dr Maponga noted the need to consider biodiversity and efficacy issues in traditional medicine, noting that unregulated or inappropriate use of traditional medicines and practices that could have negative or dangerous effects on both the patients and the practice. He implored the need for a regulatory framework on intellectual property rights, traditional medicine research, attitude changes and advocacy on traditional medicine, proper funding as well as adequate policies and legal frameworks. He noted that combining conventional medicine and traditional medicine would yield better results for the health system. 24

25 In plenary, delegates agreed on the need to protect intellectual property rights of traditional practitioners, and the need for proper registration of traditional practitioners. There was a feeling amongst the delegates that traditional medicine should not be integrated into conventional medicine but should continue to be a parallel complimentary alternative. 3.8 Overview of health sector issues and trends Standing in for Dr Gwinji (Permanent Secretary), Mr S Chihanga presented this session. He noted that while HIV prevalence rate is still high and TB still remaining as a cause of concern. Immunization coverage has gone down and barriers like cost and transport are affecting uptake of health services. The nation has shortage of doctors, EHTs, midwives and other important medical staff. Training of new professional is restricted as the medical school has few lecturers. He noted that the performance of the health sector is linked to the performance of the economy and donor funding is not reliable, as it is not guaranteed. Human resource constraints have also affected the technical side of the health system, e.g. repair of equipment. He cited that an enabling environment for health should embrace the following key areas: Human resources for health; Medicines; Finance; Equipment and infrastructure; Non bureaucratic management and administrative systems; Transport and communication; Health information system 25