2020 Health Budget Brief - UNICEF
June 2020ZIMBABWE2020 Health Budget Brief
2ZIMBABWE HEALTH BUDGET BRIEFUNICEF JUNE 20202020 HEALTH SECTOR BUDGET BRIEF1Key Messages and Recommendationsvvvvvvvv1The MoHCC is crafting the next National Health Strategy. The strategy needs to focus onaddressing existing gaps, speak to emerging challenges and most importantly seek to sustain thegains achieved thus far, with respect to health systems strengthening and delivery of qualityhealthcare services.Health outcomes are improving, and efforts need to be made to safeguard these gains. Overall,the percentage of children that received vaccinations increased from 69.2% in 2014 to 76% in2019. Maternal mortality rates have dropped significantly from 614 deaths per 100,000 live birthsin 2014 to 462 in 2019.The 2020 health budget still falls short of the 15% Abuja Declaration Target. Though there was aslight improvement from 7% in 2019 to 10% in 2020, more needs to be done.Per capita spending in health care is below the WHO recommended threshold of US 86.However, Zimbabwe’s per capita allocation, which had improved to US 57 in 2017, is estimatedto have sharply declined to US 21 in 2020 which puts at risk gains made over the years.The expenditure mix has significantly improved. As a share of the total budget, capital expenditureallocation was doubled from 15% in 2019 to 32% in 2020. Though this is a welcome development,the fiscal consolidation and expenditure reorientation process should be gradual, as there is riskof disruption of service delivery as massive cuts in employment costs can result in disgruntlementdue to wage erosion.Rural Health Centres were only allocated US 16 million, which is 6% of the PHCHC budget or5% of the total health budget. There is need to boost government spending on rural health centresto avoid dependence on donor financing to be able to better cater for over 70% of Zimbabwe’spopulation that lives in the rural areas.Budget execution is weak as evidenced by the huge deviations of actual expenditure from theapproved budget. Overall, the 2019, budget underperformed by 6% compared to over expenditureof 20% in 2018. In 2019, the capital budget performance worsened, underperforming by 86%.Health sector financing has dropped significantly from an average of US 745 million over theperiod 2016 – 2018, to below US 500 million in 2020. Innovative financing is needed to quickenthe pace of health care progress and achieve equity.Adjustment of figures into US for comparability was done using the IMF Article iv Report Exchange rates of ZWL 1.3 for 2017, ZWL 2 for 2018, ZWL 8.5 for 2019 and for ZWL 21.5 2020 per USD
3ZIMBABWE HEALTH BUDGET BRIEFUNICEF JUNE 20201. INTRODUCTIONThis Health Budget Brief explores the extent to which the approved 2020 budget allocation meets the health requirementsof Zimbabwe. It provides a summary of the size and composition of the health budget, primarily focussing on adequacy,allocative efficiency, effectiveness and equity of the current and past health spending. The Budget Brief also looks at thesources of health sector financing, mainly focussing on sustainability. This Budget Brief suggest some recommendations onways to improve health public spending, which is meant to inform future decision-making regarding budget formulation,execution, monitoring and evaluation. and budget formulation and implementation process.2. BACKGROUND AND SITUATIONALANALYSISThe National Health Strategy (NHS) (2016-2020) givesstrategic direction for the provision of healthcare services inZimbabwe. The strategy is aligned to the SustainableDevelopment Goals (SDGs), particularly Goal 3 which aims atproviding equitable quality health care services to allZimbabweans, with a focus on promoting primary health care. Thekey priorities are to reduce morbidity and mortality due to suchdiseases as HIV, TB, Malaria and NCDs. The National HealthStrategy is in its last year of implementation, and the Ministry ofHealth and Child Care is in the process of developing its successorfor the period 2021 -2025. The upcoming strategy, building on thegains made already, seeks to address existing gaps, speak toemerging challenges and most importantly seek to sustain thegains achieved thus far with respect to strengthening the healthsystem and delivery quality healthcare services.Health outcomes are improving, and the country has managedto post positive results on most of healthcare indicators overthe past 5 years. However, there are some arears which arelagging that require extra effort to yield positive results. Box 1below gives a snapshot of the sector performance for selectedindicators. Overall, the percentage of children that receivedvaccinations increased from 69.2 percent in 2014 to 76% in 2019.Maternal mortality rate dropped significantly from 614 deaths per100,000 live births in 2014 to 462 in 2019. All Early Childhoodmortality rate improved over the same period, except for neonatal,which increased from 29 deaths per 1,000 live births to 32 in 2019(Figure 1). The number of births attended by a skilled professionalalso increased from 78% in 2014 to 86% in 2019 (MICS 2019).BOX 1: Highlights of the overall health sector performanceFigure 1:Early Childhood Mortality RatesFigure 2:807570605550403029295069All Basic6525212120NeonatalInfantMICS 2014Post-NeonatalDHS 2015DPTChild78%Figure 4:86%77%MICS 2014DHS 2015Source: Various Budget Statements and Author CalculationsInstitutionaldeliveriesMICS 20199160DHS 201580100MICS 20149Birthattended by skilled Health Personel in SeclectCountries (latest data %)43 40 38 37 3656 53 4672 6681913419 2857 60 62 63 6444 47 5412 12 1022 18 1496010088 88 90 91 9478 82 86SomaliaSouth NamibiaSwazilandMalawiRwandaSouth AfricaBotswanaSkilled attendant atdelivery4086%9Antenatal carecoverage20MICS 2019MICS 2019Reproductive 68385Hepatitis B321093%69Hib14Figure 3:Vaccinations47200Under-fiveMAttendedNot attended
4ZIMBABWE HEALTH BUDGET BRIEFDespite the positive gains indicated above, the sector is facingsignificant challenges which are negatively impacting theachievements of the targets in the National Health Strategy.These challenges which range from inadequate funding, shortageof foreign currency to import essential drugs and equipment,power outages and intermittent fuel supply, which hassignificantly impacted on the operations of health care centres,depreciating local currency and increasing inflation, which haseroded the health budget, among others. In the outlook, thesedownside risks will continue to hamper performance of the sectoras the macroeconomic environment continue to be in distress.Addressing these macro-challenges will be critical for enhancinghealth results.UNICEF JUNE 20203.HEALTH SPENDING TRENDSThe health sector was allocated US 300 million in 2019representing a 13% increase from the 5-year average ofUS 264 million, recorded over the period 2015-2019.Compared to 2019 the health budget has increased by 139%.However, the increase has only brought the health budget to thepre-2019 levels, as the budget had dropped significantly in 2019to US 126 million.In nominal terms the health budget amounts to US 300 millioncompared to US 141 million in 2019. In real terms this isequivalent to US 254 million in 2020 compared to US 131 millionin 2019. As shown in Figure 5, Government health spending hasbeen declining indicating the mounting fiscal pressures. However,the rebound in 2020 is dependent upon the ZWL being able tomaintain its value. With the continued exchange rate depreciationand inflation increasing, in real terms the 2020 budget could bereduced. Since late 2018, the real health budget is being severelyeroded by the combined effect of exchange rate depreciation andincreasing inflation.Figure 5: Nominal and Real Expenditure 411501311005002016201720182019Nominal expenditurel The MoHCC is crafting the next National HealthStrategy. The strategy needs to focus on addressingexisting gaps, speak to emerging challenges and mostimportantly seek to sustain the gains achieved thus far,with respect to strengthening the health system anddelivery quality healthcare services.l Health outcomes are improving. Overall, the percentageof children that received vaccinations increased from69.2 percent in 2014 to 76% in 2019. Maternalmortality rates have dropped significantly from 614deaths per 100,000 live births in 2014 to 462 in 2019.All Early Childhood mortality rates have improved exceptfor neonatal, which increased from 29 deaths per 1,000live births to 32 in 2019.l Government needs to continue to strengthen the publichealth system by improving institutions (governance),enhancing human resource capacity (especiallycommunity-based health workers) and addressinginfrastructure deficits.Zimbabwe’s per capita spending in health care is below theWHO recommended threshold of US 86 (Figure 6). However,Zimbabwe’s per capita allocation has improved significantly toUS 57.00 in 2017. This, therefore, suggest the need for theGovernment to increase its level of funding to achieve betterhealth outcomes and make progress towards the SDGs.Figure 6: Per Capita Health Expenditure for selected countries1008680US Key Takeaways2020Real KenyaWHO TargetSource: WHO Global Health Expenditure database / Various Budget Statements
The Government budget allocation on health care accounts for10 percent of the national budget, an improvement from anaverage of 7% over the past years. As a share of the totalbudget the health budget is 10% compared to 7% in 2019 and1.7% of GDP compared to 0.8% in 2019 (Figure 7).Figure 7: Health sector spending trends against 201720182019% of GDP5ZIMBABWE HEALTH BUDGET BRIEFUNICEF JUNE 2020% of Total Budget4. COMPOSITION OF HEALTHSPENDINGComposition by Economic ClassificationTotal recurrent expenditures have been cut from 85% in 2019to 68% in 2020. There is significant re-orientation of the budgetmix in favour of investment projects. As a share of the total, in2020 the capital budget was allocated 32% (US 96.61 million)compared to 15% (US 22.7 million) in 2019 (Figure 8). This ismainly because of the significant cut of the wage bill from 34%in 2019 to 22% in 2020. Furthermore, the operational budget wasalso cut to 46% of the total budget compared to 51% in 2019.22020Abuja Declaration TargetFigure 8: Composition of Health Budget by EconomicClassificationSource: WHO Global Health Expenditure database / Various Budget Statementsl Health as a share of government spending has remainedbelow the Abuja Declaration commitment for domesticspending. Improving fiscal space through innovativedomestic financing is critical to boost health spending.Zimbabwe is a highly informalized economy and clearstrategies to harness resources from the sector will becritical in enhancing fiscal space to allow for moreresource allocations to all social sectors.l Per capita spending on health care is below theWHO recommended threshold of US 86. However,Zimbabwe’s per capita allocation, which had improvedto US 57 in 2017, is projected to have slipped toUS 21 in 2020.Percent of Total3251464020342220192020Employment costOperationalCostInvestmentSource: 2019/2020 Budget StatementThe expenditure mix rebalancing in favour of the developmentbudget is a welcome development. Though this massive fiscalconsolidation by government, which seeks to rebalanceexpenditure in favour of the development budget, is a welcomedevelopment. There is need to strike a balance betweenexpenditure reprioritization and maintaining a certain level thatguarantees a decent welfare of health sector personnel, to avoidservice delivery interruptions from industrial action as waswitnessed in the last quarter of 2019. At 22% of total, theemployment cost budget is now low and could threaten servicedelivery. Figure 9 shows this change, per programme, whichshows a rapid expansion of the capital budget for Primary Healthand Hospital care and Public Health Programmes.Figure 9: Composition of Programme budget by EconomicClassification2020192019182020PHCHCl The health budget allocation increased from an averageof 7% in the past five years to 10% in 2020. Withoutcompromising fiscal sustainability, Zimbabwe shouldcontinue to gradually increase health spending to ensuresustainability of existing achievements.600PolicyandAdminKey Takeaways1580PublicHealthThe total Government health spending as a percentage of totalGovernment expenditure falls short of the recommended 15%Abuja Declaration Target. Although the health budget still fallsshort of the 15% Abuja Declaration Target, there is a remarkableeffort by Zimbabwe to meet its international commitment. Asshown in Figure 7, health sector spending as a share of the totalbudget increased from 7% in 2019 to at 10% in 2020. For theperiod 2016 – 2019, health spending has been averaging 7% as ashare of the total budget. Similarly, as a share of GDP, health carespending has slightly increased from 1% in 2019 to 2% in 2020.The improved budget allocation will go a long way to enhancehealth outcomes, and the country is encouraged to continuegradually increasing health spending budget to achieverecommended international 9125320Employment Costs4060Other Non-Wage Recurrent Exp80CapitalSource: WHO Global Health Expenditure database / Various Budget Statements100
6ZIMBABWE HEALTH BUDGET BRIEFUNICEF JUNE 2020Primary Health and Hospital Care (PHCHC) accounts for 90%(US 274 million) of the allocated US 300 million to totalhealth budget (Figure 10). This represents 101% increase fromthe 2019 budget of US 136 million. Compared to 2019, allPHCHC subprograms budgets were increased, with the highestupward review for programme management. Of this amount,38% is earmarked for programme management. Compared to2019, programme management budget has increased by 234%(Figure 11). Central Hospitals were allocated US 60 million,Provincial hospitals US 43 million, and district hospitals US 57million. Rural health centres, which have traditionally relied ondonor financing, were allocated only 6% of the PHCHC budget(US 16 million) which appear inadequate relative to the needs as70% of the total population of Zimbabwe resides in rural areas.Figure 10: Composition of 2020 Health Budget by Programme (inUS millions and Percent of Total)4%117%20US MillionsFigure 12: Composition of Public Health BudgetComposition by .21.01.40.1NCDsR&DCDs2019FamilyHealth2020Prog. 0%Percent Change (RHS)Policy and Administration received 4% (US 11 million) of thetotal health budget. The Policy and Administrtaion budget isearmarked for policy planning, formulation and direction. It alsocovers issues to do with quality assuarance and coordination ofthe Ministry’s service delivery at provincial level. As shown inFigure 13, Finance and Administration accounts for the largestshare and was allocated US 4.2 million, which is 37% of thePolicy and Administration budget. Human resouces which ismeant for trainining, development and retention of staff receivedUS 2 million (18%). Similarly US 2 million was set aside forprovincial coordination and Administration. Unlike in the 2019budget where no resources were set aside for internal audit, the2020 budget allocated US 0.4 million for the provision of objectiveassuarance and internal controls.Figure 13: Composition of Policy and Admin (US million)27490%Policy and AdministrationPublic HealthPHCHC2.060.430.840.750.97Source: 2019/2020 Budget StatementsFigure 11: Primary Health Care and Hospital Care2.03250%US Policy Planning and CoordinationFinance & AdminProvincial Admin4.18200%9880Minister and PS' OfficeHRM&EInternal Audit4338121816Rural HealthDistrict andCentre and General HospitalsCommunity Care2019382020ProvincialHospitalsCentral Hospitals100%50%0%Percent Change (RHS)Source: 2019/2020 Budget StatementsPublic Health was allocated US 20.4 million up from US 6million in 2019. The Public Health budget constitute 7% of thetotal planned Ministry of Health and Child Care spending. Allsubprogramme budget under Public Health were increasedcompared to 2019. Non-Communicable Diseases (NCDs) receivedthe largest share of US 6 million (29%), Communicable Diseases(CDs) and Research & Development (R&D) were allocatedUS 4.5 million (21%) each. Family Health received US 3.5 million,programme management US 1.4 million and Environmentalhealth US 0.5 million (Figure 12).Key Takeawaysl The expenditure mix has significantly improved. As ashare of the total budget, capital expenditure allocationwas doubled from 15% in 2019 to 32% in 2020.Compared to 2019, total recurrent costs have beenreduced from 85% to 68% of the budget, mainly onaccount of employment costs which were cut from34% in 2019 to 22% in 2020. Though this is awelcome development; the fiscal consolidation andexpenditure re-orientation process should be gradual, asthere is risk of disruption of service delivery asemployees will be disgruntled with the wage cuts.l Rural Health Centres were only allocated US 16 million,which is 6% of the PHCHC budget or 5% of the totalhealth budget. There is need to boost governmentspending on rural health centres to avoid dependenceon donor financing. Over 70% of Zimbabwe’spopulation lives in the rural areas, and that is wherethere is greatest need.
ZIMBABWE HEALTH BUDGET BRIEFUNICEF JUNE 202075. BUDGET CREDIBILITY ANDEXECUTIONBudget execution is weak as evidenced by the huge deviationsof actual expenditure from the approved budget. Weak budgetimplementation is the major obstacle towards achieving betterhealth outcomes. Overall, the 2019, budget underperformed by6% compared to over expenditure of 15% in 2018. (Figure 14). In2018, huge budget overrun was mainly on account employmentcosts that more than doubled compared to the approved budget.Figure 14: Budget execution by economic classification, 2018 -19108%27%15%-3%-6%-50%-62%Employment Costs-86%OperationsInvestment2018Total Budget2019Source: Various Budget Statements and Author calculationsCapital budget expenditure is very weak and should bestrengthened and be prioritised. In 2019, the investment budgetperformance worsened, underperforming by 86%. Out of theZWL 192 million (US 22.7 million) allocated to the capital budget,only ZWL 26 million (US 3.1) was utilized. This is despite massiveinfrastructure gap and inadequate medical equipment, which isnegatively impacting on health outcomes. Over-expenditure onemployment costs declined significantly from 108% in 2018 to27% in 2019 in line with the government thrust to contain thewage bill. Execution of other non-wage recurrent costs (operationsbudget) improved significantly and is almost in line with theapproved budget at -3% deviation in 2019.Execution of the Primary Health Care and Hospital Care (PHCHC)programme has significantly improved, underperforming by only4% in 2019 compared to budget overrun of 25% in 2018(Figure 15). Similarly, implementation of the Policy andAdministration programme has also improved. Of concern is thePublic Health programme which is perennially underperforming.Figure 15: Budget Execution by ProgrammeKey y Health Care and Hospital Care-37%2018Public HealthThe Public Health Programme supports communicable and noncommunicable diseases, family and environmental health andresearch and development, all critical pillars of the health caresystem. Some of the challenges undermining budget executioninclude weak fiscal space, delays in disbursement of funds byTreasury and weak procurement capacity, among otherconstraints. As such, UNICEF needs to continue working withTreasury and line Ministries to strengthen budget executioncapacity, particularly for capital projects.-44%2019Policy and AdministrationTotall Budget execution is weak as evidenced by the hugedeviations of actual expenditure from the approvedbudget. Overall, the 2019 health budget underperformed by 6% compared to over expenditure of 15%in 2018.l Capital budget expenditure is very weak. In 2019,the performance worsened, underperforming by 86%.Similarly, the Public Health programme is perenniallyunderperforming by huge margins, by 44% in 2019.
8ZIMBABWE HEALTH BUDGET BRIEFUNICEF JUNE 2020Health sector financing has dropped significantly from anaverage of US 745 million over the period 2016 – 2018, tobelow US 500 million in 2019 (Figure 16). The decline can beattributed to impact of both increasing inflation and depreciatinglocal currency, which has significantly eroded domestic financing.In 2019, financing from the Consolidated Revenue Fundamounted to US 141 million (ZWL 1.2 billion). This represented19% of the total health financing. With the local currencydepreciating significantly, the budget contributed 26% (US 140.6million) of the total health sector financing, compared to US 385million (72%) by development partners. The 2020 budget has setaside ZWL 6.45 billion (US 300.4 million), which is equivalent to64% of the total health sector financing. Retained revenues (feesand levies) will contribute 1%, with the rest comprising of supportfrom partners and local authorities.Figure 16: Trends in the Main Sources of Health Sector Finance(US 31505282328229171413002018201920202017Budget Revenue3Retained RevenueDevelopment PartnersLocal AuthoritiesSource: Various Budget Statements, MoHCC and CHAI 2019 ReportExternal financing contributes an unsustainably huge proportionof the health sector financing. Development Partners areexpected to contribute US 150 million in 2020, compared toUS 385 million (72%) in 2019. Figure 17 shows trends in themain sources of health financing. This situation demands thatFigure 17: Trends in the Main Sources of Health Sector Financing(%), 2016 -20252133248Percent6. FINANCING OF HEALTH SECTOR3442016Budget Revenue57574337392017Retained Revenue2018Development Partners1726412620192020Local AuthoritiesSource: Various Budget Statements, MoHCC and CHAI 2019 Reportsources for domestic resources be strengthened, focusing onnon-traditional sources including the private sector. Consideringthe COVID-19 pandemic, external financing is likely to be reducedas all traditional external financiers are grappling with measuresto contain the outbreak, which has overstretched resourcesglobally. Innovative financing is needed to quicken the pace ofhealth care progress and achieve equity.The 2020 budget also set aside ZWL 282 million (US 13 million)for transfers to subnational governments, targeting interventionsin the health sector. This is equivalent to 3% of the total healthsector financing, with special focus on infrastructure. Thisresource if properly utilized will boost the health system at locallevels. This policy measure provides an opportunity to addressexisting inequalities and enhance equity between rural and urbanlearners.Key Takeawaysl Health sector financing has dropped significantly froman average of US 745 million over the period 2016 –2018, to below US 500 million in 2020. Innovativefinancing is needed to quicken the pace of health careprogress and achieve equity.
June 2020UNICEF 2020 Budget BriefZIMBABWE2018 National Budget BriefAn Overview AnalysisFor further information, please contact:Tawanda ChinembiriChief of Social Policy & ResearchUNICEF ZimbabweEmail: tchinembiri@unicef.orgPhone: 263 8677 020888
This Health Budget Brief explores the extent to which the approved 2020 budget allocation meets the health requirements of Zimbabwe. It provides a summary of the size and composition of the health budget, primarily focussing on adequacy, allocative efficiency, effectiveness and equity of the current and past health spending.
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