Fiscal Austerity and the health sector

OVER the years, analysis of the Health budget has tended to restrict itself to examining conformity with the Abuja Declaration which state that at least 15% of the national budget must be allocated to health.

By Taurai Nyandoro

Nonetheless, the approach presents limitations in that it reduces us to celebrate a mere satisfaction of the 15% threshold, without evaluating the salient propositions on specific allocations such as unbalanced appropriations in favour of policy and administration versus direct service delivery and value for money.

The latter becomes important taken in light of our on-going macro-economic instability characterized by currency and price distortions underpinned by a budget trumpeting austerity.

It is internationally acknowledged that health together with other social sectors such as education are consumptive and as such, may not be subjected to generalized austerity measures. If anything, fiscal policies must strive to improve, grow, sustain and consolidate health care delivery through a variety of innovative measures.

In view of the forgone, this installment of the post-mortem 2019 health budget, elucidates on two key salient fiscal issues, central to delivery of health services, namely the real monetary value of the National Aids Trust Fund (NATF) and domestic financing for retention of health care workers.

Against a background of poor economic performance and weak monetary environment, health advocates expected the 2019 national budget to pronounce measures to safeguard NATF. The overarching motivation is to ensure the fiscal policy becomes a quintessential instrument to support full implementation of our National Strategic Plans, in this case the National Health Strategy (ZNHS 2016-2020) and the Extended Zimbabwe National HIV and AIDS Strategy (ZNASP3 2016-2020).

NATF which is commonly referred to as the AIDS levy was birthed in 1999 and instantly morphed into a global best practice on domestic financing for HIV and AIDS. The AIDS levy is administered by the National Aids Council (NAC) itself a creature of Parliament mandated to superintendent the multistakeholder response to HIV and AIDS.

The most recent reviews of the country’s progress towards ending AIDS as a public health threat, present very positive reading with the HIV prevalence among the general population going down to around 14% in 2016 from 28% in 1997, 84% of the estimated 1.4 million persons living with HIV on ART and viral load suppression prevalence at around 85%.

What is abundantly clear is that all and sundry need to continue pulling northwards if the country is to sustain these remarkable feats. Nonetheless, it seems the policy makers in their acts of omission and commission are inadvertently presenting themselves as merchants of regression.

The 2019 fiscal statement failed dismally in its timid attempts to underwrite the government’s position on investments to end AIDS by ensuring real time monetary value of the AIDS levy.

Although the NATF receipts rose to $36.4 million in 2017 from $32.3 million in 2016, the real time value has continued to plummet as a result of a weak monetary environment. The net effect of diminished value of NATF is a domestic resource failing to optimally support the treatment and prevention components of the AIDS response.

The country recently adopted the Test and Treat strategy which has resulted in nearly 8000 new ART initiations per month. This is juxtaposed against the static treatment targets for the Global Fund, of 710000 PLHIV and 215000 by the US Government which are the two biggest funding streams for HIV and TB in Zimbabwe.

The demand for ART is likely to increase with the unabated new infections among adolescent girls and young women estimated at 40000 new cases per annum, and the growing demand for both Pre-Exposure Prophylaxis (PrEP) and Post Exposure Prophylaxis (PEP).

These developments are pitted against the projected ARV treatment gaps estimated at US$13 million by 2019 representing a patient gap of 228503 which will likely continue to grow.

Ironically, the government announced the introduction of Dolutegravir (DTG) treatment regimens which it notes are cheaper, nonetheless there is silence on financing modalities. This picture does not account for the prospects of stock raptures in the medium term as the country is already dispensing ARVs from its buffer stocks.

The dicey situation is further exacerbated when one takes into account that the NATF is expected to meet the current treatment gaps including the procurement of legacy Nevirapane regiments and the government shoulder the treatment targets as the main external funding mechanisms start to cut down on their treatment support.

Added to this, is real risk of the Global Fund (GF) withdrawing 15% of the current grant of US$ 502 million as the government continues to dither on its 15% contribution as per grant agreement. This creates a funding conundrum for the three epidemics of Malaria, TB and HIV which are heavily dependent on the GF and PEPFAR funding.

Certainly the stakes are so high, that pro-active fiscal interventions in the 2019 budget were a priority. The real danger is that the country will miss its ZNASP3 targets.

The AIDS levy apart from being the main source of funding for procurement of ARVs is earmarked to support procurement of other essential medicines to treat HIV co-infections such as cancer and diabetes which are the leading causes of death among PLHIV. It has been shown that cervical cancer account for 33% of all the cancer cases among women and that women living with HIV are four times likely to experience cervical cancer.

About 50% of cervical cancer cases result in death because of a combination of intertwined factors chief among them being prohibitive costs. The prevailing cancer treatment costs imposes financial barriers to the majority of women who require treatment services thus increasing the chances of death due to treatment failure. It is CSOs considered view that a dollarized AIDS levy provides a viable domestic source of funding for cervical cancer treatment. Addressing the cancer threat dictate a shift from rhetoric and simple campaign awareness to real financing for cancer treatment and ensure services are relatively affordable.

I will now turn my attention to the emotive issue of Human Resources for Health (HRH) retention scheme which has largely been funded by donors’.  The Global Fund (GF) is supporting a retention scheme targeting 24000 health workers on an annual budget of US$10 million. Sadly, the retention scheme terminates at the end of 2018, with the government yet to secure alternative funding, let alone finalize a sustainability plan as agreed with the main funding streams.

The retention scheme is a vital component of the HIV and AIDS response. The termination of this scheme presents an Achilles’ heels for the government and will likely result in a surge in health workers’ striking. Early signs indicate a restive health workforce which further dents the country’s efforts of ending AIDS and realization of Sustainable Development Goal 3 (SDG).

It does not escape attention that SDGs are interlinked with either progress or regression in one affecting the others.

In closing, we proffer the following recommendations: Ensure NATF is converted to USD value and that procurement of ARVs is high on the RBZ priority list; immediately avail the government’s 15% contribution to the current Global Fund Grant; Ring-fence and prioritize fiscal savings for health delivery in line with our ZNHS and ZNSAP3.

Taurai Nyandoro is Director Zimbabwe Aids Network and can be contacted on tpnya18@gmail.com

 

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