2017年-世界发展银行全球_Analyzing_Fiscal_Space_Options_for_Health_in_Zimbabwe_46页_3mb

Summary of Fiscal Space Analysis for Health in Zimbabwe

Core Content

This report provides a comprehensive analysis of fiscal space options for health in Zimbabwe, focusing on how the government can generate additional resources for the health sector under challenging macroeconomic conditions. It outlines the current financial situation, the role of development assistance for health (DAH), potential domestic funding sources, and strategies to improve efficiency in the health system.

Main Points

• Fiscal Space Definition: Fiscal space refers to the government's ability to allocate additional budgetary resources to health without compromising financial sustainability.
• Current Economic Situation: Zimbabwe has experienced a significant economic downturn since 2015, with slow growth, high debt, and limited fiscal revenues. This has constrained the ability to generate new fiscal space for health.
• Health Sector Funding: Government spending on health is low compared to regional and similar-income countries, averaging 7.3% of total government spending over the past five years.
• Development Assistance for Health (DAH): DAH is a major source of funding for health in Zimbabwe, with external resources accounting for over 50% of total health expenditure (THE). However, the reliance on DAH is problematic due to its earmarking nature and unpredictability.
• Domestic Funding Options: The report suggests potential domestic funding mechanisms such as the introduction of an AIDS levy, increasing cigarette and alcohol taxes, and earmarking 1% of VAT for health. These could generate substantial additional revenue.
• Efficiency Gains: Improving efficiency in public finance management, drug and equipment supply chains, human resources, and hospital operations is crucial for making better use of existing resources.
• Fiscal Space Scenarios: Illustrative scenarios show that even with increased domestic revenue, the current level of public spending on health is insufficient to meet the goals of the National Health Strategy (NHS). The funding gap for NHS2 is estimated at $660 million annually.
• Way Forward: The report recommends reprioritizing health in the government budget, improving efficiency through PFM reforms and supply chain improvements, and exploring sustainable domestic funding sources.

Key Information

Macroeconomic Conditions

• Zimbabwe's economy has experienced a downturn since 2015, with GDP growth slowing and public expenditures decreasing.
• IMF forecasts predict an average economic growth of 0.4% between 2017 and 2021, with government revenues and expenditures expected to remain stable at around 23% and 26% of GDP respectively.
• The country faces high debt, inflation, and unemployment, which limit the potential for fiscal space generation.

Prioritization of Health in the Budget

• Government spending on health is low compared to regional peers and countries with similar income levels.
• Despite the health financing strategy (2016-2025) aiming to increase public spending to 15% of government spending, this is unlikely to be achieved in the short term due to the economic crisis.

Development Assistance for Health (DAH)

• DAH is the primary source of health financing in Zimbabwe, with external resources accounting for over 50% of THE.
• DAH is skewed towards disease-specific programs, particularly HIV/AIDS, which has consumed a large portion of external funding.
• The reliance on DAH is unsustainable and limits the flexibility of the health sector.

Domestic Funding Sources

• The AIDS levy has been successful in generating domestic revenue for HIV/AIDS programs.
• Earmarking excise taxes on cigarettes and alcohol could generate additional revenue, but the current excise tax on cigarettes is relatively low compared to SADC countries.
• Earmarking 1% of VAT could generate up to $138 million annually, significantly narrowing the funding gap for the health sector.

Efficiency Gains

• Four major areas of inefficiency are identified: Public Finance Management (PFM), drugs and equipment, human resources, and hospital efficiency.
• Improving PFM through better budget planning, execution, transparency, and accountability is essential.
• Addressing the supply chain through a pull system and reducing parallel distribution systems can improve the availability and cost-effectiveness of drugs.
• Reducing the wage bill through public sector wage reform and reallocating posts to lower-cost staff can enhance efficiency.

Fiscal Space Scenarios

• Even with the most optimistic domestic revenue mobilization, the funding gap for the NHS2 remains significant.
• Reprioritization of health expenditure to 15% of government spending by 2020 would not be sufficient to meet the costed scenarios of the NHS.
• The report highlights the need for efficiency gains to reduce the financial burden on households and ensure the sustainability of the health financing strategy.

Way Forward

• Reprioritization of health in the government budget is necessary to increase fiscal space.
• Implementing PFM reforms, moving towards program-based budgeting, and improving the supply chain are critical steps to enhance efficiency.
• Exploring sustainable domestic funding mechanisms such as VAT earmarking and tax reforms is essential for long-term health financing.
• The report underscores the importance of policy reforms and partnerships to address the financial and operational constraints of the health sector.

Conclusion

The analysis emphasizes the urgent need for Zimbabwe to improve efficiency within the health sector and explore sustainable domestic funding sources to support the implementation of its new health strategy. Given the current macroeconomic constraints, generating fiscal space for health will require a combination of reprioritization, efficiency gains, and innovative domestic funding mechanisms.