Reflections on our personal mentoring sessions with NANGO, Zimbabwe on child-friendly budgets in the health sector, October 2012

by Russel Wildeman

Personal Mentoring

We have decided to adopt a rather grandiose term for the capacity development work we do, namely “personal mentoring.”

Partners in a number of Southern African countries who advocate on behalf of children present us with a number of key questions that they would like to see answered using budget analysis as the primary analytical method. Some of these questions are commonplace such as the composition of spending, how the budget process gives effect to the realisation of socio-economic rights, whether prioritisation of children’s needs does indeed happen etc. Some of the questions relate more to the advocacy goals of the organisation and we may field a request that states “can you develop an advocacy strategy to guide us in our annual interventions in the budget process?” This requires knowledge of independent budget analysis and the know-how to construct advocacy strategies. When organisations have done these analyses, often the questions are more sophisticated such as “how do we translate our child-fiendly framework into a budget analysis framework?”

Once we have received the questions, our task is to determine whether some or all of their questions can be answered using independent budget analysis. This is a laborious process because it requires an understanding of the documents that are available, partners’ access to government officials, the prevailing culture of openess in that country, whether the data in the budget are structured such that the information is useful etc. This results in conversations between us and partners so that we obtain the necessary documentation, study them carefully and come up with a proximate answer as to whether the questions are answerable.

Normally, on the first morning of the personal mentoring workshop, we use the time to establish an approach based on the availability of data and partners’ access to government data not published etc. The morning is also used to chart the way forward for the week in terms of the provisional programme, expected written outputs, we develop a draft outline of a possible budget paper, we agree on supervision and when drafts are to be read, technical sessions etc. We also establish rules around the physical availability of participants. So for example, if we do a technical session on inflation in the morning and the afternoon is reserved for writing, then partners can do such writing in the training venue, their hotel rooms, on a moving bus or wherever they feel most comfortable. Of course, we can also do shopping in our “free time.” At the start of each session in the morning, we assess where we are, the likelihood of achieving our set objectives for the week, revising objectives if necessary, and alter the pace at which we do technical sessions. We found this daily temperature-taking important and necessary in guiding us to a set of successful outcomes at the end of the long week.

This far, we have done this work with Save the Children Swaziland, NANGO in Zimbabwe and a group of organisations in Botswana. Remaining are visits to our partners in Mauritius, Lesotho and Mozambique. This will conclude the Idasa mentoring support to our partners in 2012.

One final observation is that we take a maximum of five participants so that we can keep the workshop small and intimate and to enable us to provide detailed technical and conceptual back-up support as the workshop unfolds.

Our personal mentoring visit to NANGO, Zimbabwe

In the case of NANGO (National Association of Non Governmental Organisations in Zimbabwe), our partner decided that the health sector should be examined because of its obvious relevance to children’s rights and well-being. Prior to our country visit, the NANGO representative sent a fresh list of questions to be considered and on the first day we (jointly) decided that the analysis will measure the relevance of allocations/spending against a child-friendly normative framework developed by NANGO. My own preference was to assist NANGO in developing an advocacy plan (based on analysis of spending trends in the health department), but these mentoring sessions are not about the preferences of the facilitators.

The documents and resources that we had access to included the following

  • Local knowledge of the health system prior to the political and economic crisis and the status quo;
  • Estimates of Expenditure, 2011 to 2014 (in Zimbabwe, the calendar year and the fiscal year are the same thing);
  • The Budget Strategy paper 2012;
  • The Medium-Term Plan, 2011 to 2015, which sets out the thinking of the government on the key social and economic sectors in the country;
  • The Adjusted budget, which was adopted in July 2012;
  • Various Health planning and strategic documents;
  • A mid-year reflection of the implementation of the Medium-Term Plan by the economic development ministry;
  • Inflation data from the Reserve Bank and the central statistical services; and
  • Various newspaper articles on the state of the economy and the health sector in particular.

Key findings

Naturally, we cannot write a paper on the facilitation work we did because that would defeat the purpose of building strong independent capacity. However, what we want to do is just give a snapshot view of what we think are key issues in the budget and spending plans of the Department of Health.

Key observations include

  • While there are disagreements whether Zimbabwe will maintain its status as having the lowest inflation rate in the SADC region, price stability has clearly been achieved. The inflation rate in 2012 is projected to be 5%, while for 2013 and 2014, projections are 5.5% and 5.7% respectively.[1]
  • Generally, projections of expenditure are optimistic as evidenced in the downward revision of approximately 10% in the Adjustment budget tabled in July 2012. This makes it hard to interpret spending plans because of the expected deviations between such approved estimates and the final outcomes.
  • However, we tend to think that projections are used as a strategic tool to lock in potential donors and other external funders. In other words, exaggerate the extent of your planned spending and hopefully those with a keen interest in Zimbabwe may invest and support such budget plans.
  • A case in  point is the Health budget, which is projected to grow by more than 14 per cent in real terms over the next three years. In the context of the downward revision in 2012 and uncertainty about the performance of the economy, one is best advised to regard those estimates with caution.
  • This uncertainty is worsened by the fact that Zimbabwe runs on a cash budget basis, which means that the allocation process is subject to intense political contestation.
  • In health, spending is skewed towards the secondary and tertiary levels of care because patient demand is now directed at these levels instead of the primary health care system, which is practically defunct. In other words, whereas a normal headache would be treated by qualified nurses in a  village, patients are now looking for basic medical care in institutions that are more wont to thinking about large and sophisticated operations.
  • Seondary and tertiary hospitals are not configured to deal with primary health care issues, are over-run and this has had a devastating impact on the level and quality of care that ordinary Zimbabweans receive. Because infrastructure in these hospitals has not been maintained, care and quality are severely compromised.
  • In fact, the neglect of medical and physical infrastructure is arguably one of the key challenges of the Government of National Unity. Rebuilding, refurbishing and maintaining infrastructure will take of years of spending to mend.
  • Government is struggling to maintain a decent supply of drugs in hospitals because of revenue shortages and rampant corruption.
  • Furthermore, government is struggling to retain the services of health professionals who are joing the private sector and emigrating to other destinations in the region, Europe and the USA.[2] This is a significant threat to the system and in the latest budget, the government has set aside resources to improve the conditions of service of mainline health personnel.
  • Funding to regulatory bodies has been severely compromised and this is a matter of concern to health professionals in the country.

Given these challenges, how is the government’s budget framework responding?

  • In terms of the financing framework, the government has been keen to make a distinction between spending on health and other social services that should be funded by own resources and those that should be funded by donor resources. Infrastructure spending falls in the latter category and in the context of the country’s dwindling infrastructure stock, this makes perfect sense.
  • Internally, however, the government’s own spending on capital is not credible and this is something that needs to be looked at in earnest. Capital transfers to institutions are part of the solution but much more robust spending is needed to deal with emergency infrastructure situations in public hospitals.
  • The government is aware of the distorted nature of health spending and aims to reverse the low emphasis and funding of the Primary Health Care system. However, our examination of the budget over the medium term suggests that such reversal are unlikely and for the foreseeable future, most ordinary Zimbabweans will be served by referral hospitals that cannot cope with the public demand for services.
  • In terms of infrastructure, the government is providing resources to public hospitals (but they are not enough, given the backlogs) and to Mission Hospitals. The latter are church-based institutions that have apparently maintained levels of care in spite of the political and economic crises. Providing funds to Mission Hospitals is akin to funding private schools in RSA because of the financial burden they remove from the State and because of the quality of service they provide. The government’s capital transfers and subsidy to these mission hospitals are projected to grow in real average annual terms by approximately 21 per cent over the next three years.
  • A strong growth framework has been put into place to deal with demands and pressures on the referral hospitals and in this regard, spending for such public hospitals is projected to increase by 60 per cent in real terms on average over the medium term.
  •  Government has offered some increases to health professionals, but the strategy does not appear to be aimed at attracting new professionals to the sector but merely retaining those who are in the employ of the government. In other words, the present spending plan will not stop the brain drain, nor will it lead to substantially higher number of medical personnel.
  • Encouraging, however, is the improved funding to regulatory bodies. This should help to improve health alerts and minimise (although not eliminate) the risk of hospital-induced infections.

Concluding remarks

What we have done in this short piece was to faciliate a broad and macro analysis of the health budget in Zimbabwe. Our partners are now taking this basic analysis and further analysing the budget using their child-friendly framework.

Our partner in Zimbabwe is scheduled to give us a draft soon after which we will start the process of helping them to complete a written piece that will be used to

  • make submissions to the relevant portolio committee,
  • publish and disseminate the findings in a local newspaper,
  • Write an op-ed piece on their analyses and recommendations, and
  • Extending the training we have provided to affiliates in the provinces.

[1] The CPI deflators used in our work are 2011/12 (1), 2012/13 (1.05), 2013/14 (1.10775), and 2014/15 (1.170892). Information on inflation was obtained from the Treasury and projections from the Budget Strategy Paper, 2012.

[2] There is another view, which suggests that the qualified staff (especially nurses) are available but the government is not in a position to increase the public sector wage bill.

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