THE VICE PRESIDENT AND MINISTER OF HEALTH AND CHILD CARE (HON. GEN. (RTD.) DR. CHIWENGA): I will present a Ministerial Statement in response to the issue of maternity user fees policy and maternity mortality which was raised by Hon Dr. (Thokozani) Khupe in this august House on 3 June 2021.
Let me begin by giving a brief historical background of user fees in our public health care system. After Independence in 1980, Government announced that any person earning less than Z$150 per month was entitled to free health care in the majority of public health facilities with the exception of Parirenyatwa Group of Hospitals and a small number of other high level referral hospitals. This exemption policy saw a threefold increase in clinic attendance. However, the slow growth of the economy from 1983 upwards coupled by an increasing population put pressure on the delivery of health services and gave birth to the need for user fees.
In the 1990s and as part of Economic Structural Adjustment Programme (ESAP), user fees were introduced with increases being applied throughout the early 1990s. However in 1995, user fees were abolished in rural health centres and rural hospitals. Up to 1997, the fees collected were sent to the Ministry of Finance and this was seen as a disincentive to health facilities and the Ministry of Health and Child Welfare. In 1997, the Health Services Fund was established seeking to provide additional revenue to fund health service by collecting fees from users and retaining 40% at district level while the remaining 60% was surrendered to the Ministry of Health for use in rural health centres in the districts that the Health Services Fund was collected.
The Health Services Fund is still operational to date as shown by the following balances in some of our health institutions. Gwanda Provincial Hospital, $538 089. Chinhoyi Provincial Hospital, $350 000, Victoria Chitepo Provincial Hospital, $76 200 and Chitungwiza Central Hospital, $100 000.
The Ministry is also aware of Section 302, Constitutional provision that all fees, taxes, borrowings and revenue of Government must be paid into the Consolidated Revenue Fund, unless an Act of Parliament permits an authority that receive them to retain them in order to meet the authority’s expenses. Discussions are in progress for Treasury to ring fence Health Services Fund within the Consolidated Revenue Fund, in compliance with the provision of the Constitution.
In 2001, Government abolished all maternal fees in public health institutions, except central hospitals. Consultations and drug fees at primary care level, that is at rural hospitals, Government, Mission and Rural District Council clinics were also abolished. The following users were to be exempted from paying user fees at all levels of care as part of social protection: children under five years old, pregnant women, except at central hospitals, over 65 year old, mental patients and cases of communicable diseases. Patients who disregarded the referral system were to be charged fees for consultation, diagnostic procedures, treatment, drugs and admission where applicable. In 2009, the Government reintroduced user fees. This time in foreign currency, at Government hospitals to generate funding for health services as service delivery for most of the health institutions had collapsed during years of hyperinflation.
Current Policy on maternal fees
In 2011, fees for pregnant mothers were removed, after there was advocacy for the abolition of user fees for maternity services and subsequent treatment of infants after delivery. Funds to support the fee removal were channelled to health facilities through the Result Based Financing (RBF) initiative supported by the World Bank (WB) in 18 districts from 2011 and the Health Transition Fund (HTF), a multi-donor pooled fund managed by UNICEF in 42 districts. The Health Transition Fund later evolved to the Health Development Fund, running from 2016 to 2020. The World Bank-supported Result Based Financing Programme was handed over to the Government in 2018, with the Government through the Ministry of Finance, now being responsible for funding disbursements to health facilities in the 18 front runner districts.
From 2016, the Ministry of Health and Childcare with support from the World Bank, also embarked on a pilot voucher system in Harare and Bulawayo to subsidise maternity services in urban as the result-based financing system does not cover the two urban provinces of Harare and Bulawayo. This voucher system continues to be funded to some extent but have seen periods where no funding was available. As a consequence, City Health Authorities in both cities continue to charge fees for health services, including maternity services although in practice, many patients who are unable to pay do receive free treatment.
Although Government has adopted the policy of free maternity services in the public sector, the cost remain and have to be met somehow. On that front, all public health institutions, including central hospitals are entitled to submit to Treasury claims for services rendered for free to pregnant women, under five year olds and over 65 years old patients. This is the current operational position, though it needs to be constantly monitored and strengthened.
Non-Compliance with the user fee policy
In an update to Cabinet in February, 2018, the then Minister of Health and Childcare indicated that while most primary facilities were not charging user fees, some council facilities were still charging fees. In addition, while most hospitals were applying the user fee policy and complying with the exemptions provided, it was noted that there was a need for some sort of support to ensure the sustainability of the facilities, hence the Treasury claim position now in operation.
In addition, though the policy stipulates “no user fees” in rural clinics, some of form of user fees payable at the point of service are being charged, mostly by the Rural District Councils owned clinics, ranging from consultations and service fees, medicines or drug fees, card fees, security and development fees.
Unofficial non-monetary user fees
Furthermore, programme monitoring visits such as the Joint Review Mission and Supportive Supervision visits have also noted that a number of health facilities including those at primary level are requesting patients, particularly pregnant women to provide some commodities required to access services. There are some reports of health facilities, largely Mission Hospitals, requesting maize, grain, chicken, goats and work by relatives as a form of payment for services given.
A UNICEF U-Report poll administered in September 2019 on 10 119 users of health facilities revealed that 70% of pregnant women who responded had been requested to bring some items for delivery. However, the responses also included commodity not related to the health services such as baby towels, nappies or pampers, sheets, food et cetera. The proportions all differed by geographical areas or provinces.
5. Antenatal Care (ANC)
As a result of Government policy of free maternity services, the following positive developments have been realised:
· The proportion of pregnant women with at least four antenatal visits has been increasing since 2014. The Multiple Indicator Cluster Survey (MICS) revealed an increase by about two percentage points from 70% in 2014 to 71.5% in 2019.
·The Multiple Indicator Cluster Survey also showed an increase in the number of pregnant women booking early to about 4 in every 10 pregnant women in 2019, up from 3 in every 10 in 2014.
6. Labour and Delivery
Deliveries in health facilities have consistently remained high (above 80%) since 2014 and this has been corroborated by findings from Multiple Indicator Cluster Survey in 2014 (80%) and 2019 (86%).
Pursuantly, skilled attendance at birth has also remained high over the years with 8 in 10 deliveries being done by either a nurse or a doctor since 2014. However, as with antenatal, poor quality of delivery care remains the main obstacle to better delivery outcomes. As such human factors including lack of expertise, poor attitude and human error account for 80% of all maternal deaths that occur in health facilities.
7. Post Natal Care (PNC)
Post Natal Care coverage for the mother increased from 77% in 2014 to 82% in 2019 (MICS). Postnatal care coverage for the new-born baby also increased from 85% in 2014 to 91% in 2019 (MICS).
8. Maternal Mortality
Mr. Speaker Sir, maternal mortality ration (MMR) is commonly recognised as a general indicator of the overall health of a population, of the status of women in society, and of the functioning of the health system. High maternal mortality ratios are thus markers of wider problems of health status, gender inequalities, and health services in a country.
Maternal Mortality Ration has been on a downward trend in Zimbabwe since 2002. Findings from the Multiple Indicator Cluster Survey show a decrease by 25% from 614 per 100 000 in 2014 to 462 per 100 000 live births in 2019.
9. Effects of Non-Compliance to the User Fees Policy
The Ministry is aware of the effects of health facilities continuing to charge user fees in contravention of the exemption policy from user fees:
· There is decreased use of services by those members of the community that are not able to afford the user or related fees.
· There is overburdening of nearby facilities that might offer the services for free as people move from the charging facilities and this has been the case especially in Harare.
· Patients delay seeking treatment until it is too late to assist them resulting in loss of lives sometimes both the mother and the baby.
·Patients bypass health facilities to seek treatment from alternative sources.
· There is generally non-compliance to treatment.
· Patients are tempted to share drugs with other patients and engage in self-medication.
·There is risk of patients purchasing unregistered, spurious, falsely labeled, falsified and counterfeit medicines from black markets.
·Patients engage in corrupt activities in connivance with health workers to access health care services.
10. Policy Implementation
Mr. Speaker Sir, in conclusion and to ensure implementation of the National Development Strategy (NDS) 1 on health and well-being;
· The Ministry of Health and Child Care is in the process of absorbing into the mainstream, all local authority healthcare delivery platforms which include clinics, polyclinics, rural hospitals and infectious disease hospitals. In this regard, the Ministry is in the process of filling the gap of provincial medical directors for Harare and Bulawayo Metropolitan Provinces who will be reporting directly to the Ministry. This will standardize health service delivery, among other things, addressing both the welfare of health workers and Government user fee policy positions.
·Provincial medical directors are the focal persons working directly with the Provincial Ministers of State and Devolution as part of the implementation process of the devolution policy in the provision of all public health services in the provinces.
· In addition, the Ministry has just crafted the National Health Strategy (2021 to 2026) which includes a significant reduction of institutional maternal mortality as a key deliverable.
· The National Health Strategy has a monitoring framework to ensure implementation and equitable access to health services across the country. I thank you.