2015年-世界发展银行全球_Health_Public_Expenditure_Review___Zimbabwe_86页_3mb

Summary of Public Expenditure Review for Health in Zimbabwe

Core Content

This Public Expenditure Review (PER) for health in Zimbabwe, conducted in May 2015, is a collaborative effort between the World Bank Health, Nutrition and Population Task Team, the Ministry of Finance and Economic Development (MOFED), and the Ministry of Health and Child Care (MOHCC), with input from various development partners. It builds on the 2013 Health Sector Policy Note and provides an in-depth analysis of the health sector's financial landscape, performance, and challenges.

Main Questions Addressed

The PER focuses on the following key questions:

• What are the health priorities on which spending should focus?
• What are the needs of the public sector relative to health inputs and outputs?
• What are the major sources of health financing in Zimbabwe?
• What are the total level, composition, and distributional aspects of health care spending?
• Do government expenditures enhance efficiency and equity in the sector?
• Given limited public spending levels, what sources of additional financing are possible?

Key Findings

1. Health Outcomes and Needs

• Health Status and Risks: Life expectancy has improved, maternal and infant mortality have declined, and HIV and tuberculosis prevalence have reduced. However, NCDs now account for 31% of all deaths in 2012.
• Lifestyle and Risky Behaviors: Unhealthy diets, physical inactivity, risky sexual behaviors, and high smoking rates are contributing to the worsening health profile.
• Service Utilization and Health-Seeking Behavior: There is a significant disparity in the use of health services between poor and rich populations. Poorer individuals tend to use lower-quality facilities, while wealthier individuals access better services.
• Quality of Care: Major gaps exist in the delivery of maternal and newborn care, and overall quality of care is low, especially in rural areas.

2. Health Expenditures

• Government Health Expenditures (GHE): Per capita GHE is comparable to the Sub-Saharan Africa (SSA) average, but the high proportion of out-of-pocket (OOP) spending raises concerns about regressivity.
• Donor Financing: Donor spending has increased in recent years and now accounts for about the same level as government spending. However, there is no institutionalized mechanism to coordinate donor and government financing.
• Private Health Expenditure: Private funding is limited and concentrated, with private insurance covering a small portion of the population.
• Efficiency Analysis: Zimbabwe has historically shown structural efficiency, achieving better health outcomes with lower spending. However, this advantage has diminished in recent years. There is a need for more investment in prevention and to link spending to outcomes.

3. Financing Sources and Trends

• Domestic Revenue: General tax revenue and earmarked taxes, such as the AIDS levy, are key domestic sources of health financing. The AIDS levy, introduced in 2000, has become a major funding source for HIV/AIDS programs.
• Fiscal Space: The country has limited fiscal space for health, with government spending on health accounting for 7-8% of total government expenditure.
• External Funding: External funding, particularly from the Global Fund and Health Transition Fund, has shifted from disease-specific to broader health-system support. However, coordination remains a challenge.

4. Challenges and Constraints

• Data Limitations: The lack of subnational expenditure data and outdated National Health Accounts (NHA) from 2010 limit the accuracy of analysis.
• Inequities in Service Delivery: Health personnel and facilities are concentrated in wealthier areas, leading to disparities in service quality and access.
• Regressive Spending: High OOP spending creates a regressive burden, especially on poor households. However, the incidence of catastrophic health expenditure is low, suggesting that the system may not be as regressive as it appears.
• User Fees: User fees remain a significant source of revenue for health facilities, particularly in rural areas. These fees disproportionately burden poor provinces and hinder access to care.

5. Recommendations

• Increase Domestic Resource Mobilization: The government should increase its own allocation to health and explore mechanisms such as "sin taxes" and the AIDS levy to fund emerging health priorities.
• Improve Coordination: MOHCC and MOFED should coordinate donor support and institutionalize resource planning, mapping, and tracking mechanisms.
• Enhance Efficiency: Link government spending to health outcomes through performance-based financing (RBF) and improve allocative efficiency by prioritizing prevention over curative services.
• Decentralize Budgeting: MOFED should decentralize the public financial management system to the district level to improve transparency and data tracking.
• Strengthen Health Workforce Deployment: Implement or revise schemes to encourage skilled health workers to serve rural areas, with donor-funded retention programs as a complement.
• Address User Fees: Remove user fees at the point of care, particularly for low-income households, and ensure that this is done through mechanisms like RBF or expanded insurance.
• Improve Data Collection: Enhance the MOHCC's data collection systems, including the National Health Accounts (NHA) and public financial management at the district level.

Conclusion

The PER highlights the need for more efficient and equitable health financing in Zimbabwe. While the country has made progress in some health outcomes, challenges persist in the distribution of resources, quality of care, and coordination between domestic and external financing. The recommendations emphasize the importance of strengthening domestic resource mobilization, improving efficiency through performance-based mechanisms, and enhancing transparency and data collection systems to support better health policy decisions.