No woman should die giving birth

maternal mortality ratio of a staggering 960 per 100 000 live births and slim chances of achieving MDGs 4 and 5 to reduce maternal and under-five mortality before 2015, a multi-donor pooled fund called the Health Transition Fund (HTF) was established in Zimbabwe. The objective was to curtail a potentially devastating disaster. The fund is intended to boost the country’s chances of attaining the health Millennium Development Goal (MDG) outcomes by 2015 through provision of adequate investment in the health system underpinning service delivery and long-term predictable funding from donors.
An estimated total of US$80 million is required per year over five years to achieve these objectives, and a number of donors are currently lined up to provide contributions within the period 2011-2015. Among other things, the HTF would enable some upgrading and proper equipping of some maternity facilities as well as scrapping off of maternity fees as foreseen by national policy. This is a welcome development in a context where a lot of women giving birth are opting for cheaper, unsafe delivery options or are being detained in hospital for failure to pay maternity fees.
In efforts to intensify provision of free maternity services to cushion poor women, the Government recently scrapped maternity user fees in at least 36 rural district hospitals under the aegis of the HTF. However, no sooner had the initiative been introduced did some unforeseen problems begin to surface. Because the scrapping of maternity fees was introduced in only a handful of health facilities and not others, this resulted in a lot of pregnant women — including those who can afford maternity fees — flocking there. Those health facilities offering free services suddenly found themselves inundated and overwhelmed with long queues that at the end of the day, what started off as a noble idea ended up being subtracted from. The ripple effects of this would obviously include that already overworked nurses are even more exhausted and hostile, and more women are at risk of losing their lives just waiting their turn to access the free service.
This brings us to the question of how really sustainable such a move would be in Zimbabwe. Without being insensitive to the fact that women need subsistence and support from Government in terms of accessing maternity services, we need to face the reality. Initiatives like the HTF are impermanent, unpredictable and, to a degree, unsustainable because they are prone to the vagaries of ever changing donor preferences. In any event, there is an impression that the HTF’s key endeavour is to chase the attainment of MDG targets by 2015, what next after that? How do the accomplishments sustain long after depletion of donor funds?
Advocacy for the scrapping of maternity fees is happening outside the bigger macro-economic picture. Historically, there were no health service user fee charges in public facilities, much the same way as there was free primary education. Then came the 90s Structural Adjustment Programmes (SAPs), and service fees were introduced with the particular belief that it would improve service quality and ensure access to health for the poor, underprivileged and vulnerable. But of late, pressures from the economic crisis have reduced resources to frontline services. How simple is it to revert to the utopian scenario of post-independence? Is the macro-economic environment capable of absorbing free user fees?
We need to find sustainable means of making maternity services more easily and affordably accessible. The Herald last week carried a leader headlined “Upgrade maternity facilities to decongest State hospitals”, wherein the paper made a few interesting suggestions about addressing the maternity fees question.
Among other things, The Herald suggests introduction of temporary maternal medical aid schemes for couples planning their families. That way, expecting parents would pay staggered instalments much the same way as medical aid, such that by the time of delivery, any possible complications are taken care of.
This would mean that even if there were few takers of such schemes, there would be a modest relief of pressure, as the standard State system would have fewer mothers to cope with. The newspaper also aptly suggests that the HTF should not be so shortsighted to focus only on improving facilities in main referral hospitals. Focus should also be on adequately staffing and equipping suburban council clinics to ensure that fewer mothers need ever be referred to hospitals, in the long term.
It can be added that instead of unwittingly further entrenching donor dependency, Zimbabweans can start being creative with available resources. The widely acclaimed Aids levy initiative is a notable precedence and success story in Zimbabwe, where citizens have pulled in their collective economic muscle in addressing a national problem.
The maternal fees issue requires something of a similar nature, in order to be sustainable. Countries with high development indices, for instance, are characterised by significant taxes on the working population. Populations sustain their health sector through contributions. Now, some will oppose higher taxes on their understandably already stretched pockets, particularly with concerns about corruption and misuse. But then again if well managed, investments made through those taxes can find their way back to the ratepayer in the form of improved health and social services.
The main challenge for Zimbabwe now is that, it is mainly the formal sector getting highly taxed. And Government needs to urgently address the issue of also garnering contributions from the informal sector as the majority of Zimbabweans are making a living that way, so that they can also contribute to the fiscus and lessen the burden on the formal sector.
On the other hand, while the HTF promises to improve infrastructure and service delivery in some health facilities in the short term, it will take a lot of discipline for the initiative to benefit the most needy. Zimbabweans can each play a part by being honest, so that those who can actually afford maternity fees do not access free services at the expense of those who cannot. In this way, key mechanisms can be established during the lifetime of donor support, to sustain into the future.

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