Our national health budget is about US$800 million. That is just US$50 per capita. Not a lot of money to provide health care to 16 million people. 80 per cent of this goes into the maintenance and operation of about 100 major hospitals and 1600 health clinics. Very little remains for public health services and other essential services.

The budget contribution is extended by about US$300 million a year in international aid for HIV and other major infections such as malaria. The Aids levy of 3 per cent of all salaries generates significant funds but we have no idea what they are doing with this. I have never seen an audit report on the levy or the Council that manages this. The other major input, probably the largest today, is Medical Aid. This is not insurance although it is sometimes managed as such. Contributions today probably exceed USD$1,5 billion a year and it serves the needs of perhaps 12 to 15 per cent of our population.

The fourth major contribution which is almost impossible to measure is contributions from the Diaspora. The gross income of the 5 or 6 million Zimbabweans now living outside the country is probably in excess of our formal sector GDP of US$50 billion. The recognised contribution of this in the form of remittances is just over US$2 billion. In fact, it is much more – one of the major transfer agencies reported remittances of over US$3 billion last year. My estimate is that it might be US$5 or US$6 billion a year.

We know that at least US$1,2 billion or more goes into schooling and I cannot imagine that its less in the health sector. If this is so then the total annual expenditure on health services might be about US$4,2

billion or US$265 per capita. The state budget contribution represents only 19 per cent of total expenditures. This puts the role of the State into perspective. Even if we went to the level of health expenditure recognised by the African Union at 15 per cent of the budget, it would make little difference.

What do we do about this? It is clear that the UK system represented by the National Health Service is no example to follow. It absorbs a quarter of the UK budget, is grossly inefficient and delivers a poor standard of service. The United States system of health insurance is also no example to follow; insurance costs are massive and the cost of health care probative at every level. It has created huge health care companies and insurance agencies but can only be justified in countries with per capita incomes above US$60 000 a year and even then it does not serve tens of millions and certainly not the poor elements in that society.

The first question we must answer is what would deliver basic health services at least cost. The answer to that question has been known for years – it is the local, family health care centres. We have 1600 already and all we need is to extend this network to about 2500 centres and at each of these we need a contagious disease unit, emergency services, a maternity unit and a public health unit with capacity for home visits. In addition, each of these units needs Sky link and a Centre in Harare where a doctor can be on duty 24 hours a day to provide advice. Each centre would need a small pharmacy.

To be effective these health centres should be managed by an elected Committee who would oversee its activities. Each should receive a grant each month from central Government. Every family in the Health Centre defined service area should be required to be a member and make a small monthly contribution to its operations. The Centres would be the first point of entry to the health system. It would be a referral centre and admission to a hospital would be based on a note from the clinic.

All District Hospitals should be in contact with all the Clinics in their District. They would be required to service any patients referred by one of their clinics for whatever was required. All District Hospitals should be handed over to the Communities they served. The Board to be elected by representatives of the Clinic Committees. Again, they should be funded by a grant paid mid-month by central Government, reviewed annually. The District Government would be required to also make a contribution to the hospital budget.

Provincial Hospitals should all be equipped and staffed as specialist units where whatever cannot be handled by the Clinics or the District Hospitals would be handled on a referral basis. But they should be managed by Boards elected by the districts serviced by these units. Charges for health services would be set nationally by negotiation with the Ministry of Health. The Ministry would also provide an inspection service which would involve an annual licencing process. The Ministry would also provide an audit service to ensure that all health service units are properly audited each year with the accounts published.

All staff would cease to be civil servants, instead they would be employed by the institutions they worked for at negotiated salaries. The role of the Ministry would be supervision and oversight.

The private sector should be made responsible for the supply of pharmaceutical needs with Provincial warehouses and a low cost delivery system. Sky Link to provide ordering capacity which should include all essential supplies, including cleaning materials. Private practitioners should be encouraged to use Clincs and Hospitals as a base to conduct their activities for a negotiated fee. The Aids Council to be responsible for the supply of all the medical needs of those with HIV/Aids via the Provincial Warehouse system.

The health services industry is 80 per cent funded by the private sector. The management and structure of the industry needs to reflect this fundamental. This is the also the only way we can bring the influence of enterprise, energy and initiative with integrity of the private sector to the system. At independence in 1980, my greatest concern was that health and education services would decline in quality and become available only at great cost outside the country. This has not happened, and we have available to us worldclass facilities and institutions in both fields. But these are all private not available to the majority of our people. Government health and education institutions no longer deliver a decent standard of service.

It’s no secret that anything managed by the State simply does not work. Our society is littered with institutions that once delivered good quality services and who are now in a desperate state. Government simply cannot pay decent salaries and the flight of expertise and experience in every field has been disastrous. It is also no secret that wherever our people go they are sought after for their skills and work ethics. We need to bring them home and to stop the flight.

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