World Report

Zimbabwe’s health-care system struggles on
Zimbabwe’s once proud health system is deteriorating at an alarming rate. Hospitals are facing dire shortages of doctors and medical supplies. Only political stability coupled with massive external support can reverse the situation, say experts. Andrew Meldrum reports.
As Zimbabweans vote in general elections, many will have to go to the polls by stepping over pools of raw sewage. Others will be noticeably thin and coughing, showing signs of HIV/AIDS and tuberculosis. Health indicators are worsening drastically in Zimbabwe. Hospitals in the country are unable to undertake the most basic operations because of shortages of anaesthetics, sutures, and other essential supplies. Zimbabwe’s health-care system—once held up as a model for Africa—is collapsing. President Robert Mugabe, 84 years old and in power for 28 years, is running for another 5-year term. He used to be able to campaign on the excellent health care his government offered but now Mugabe can only pledge to distribute more antiretroviral drugs, which weary Zimbabweans dismiss as empty promises. There are many factors contributing to Zimbabwe’s health-care disaster. The economy has been in crisis since 1998 and the gross national product has shrunk by more than 50%. Inflation is running at more than 100 000%. More than 80% of the country’s 13 million people eke out an existence below the government’s own poverty line. Shortages of staple foods are widespread and more than 4 million people are in need of food aid. The country is battling one of the world’s highest rates of infection of HIV/AIDS, which is estimated to be killing more than 3000 people each week. Mugabe’s regime no longer maintains basic services in the cities such as water and sewage systems. Harare, the capital, now has regular outbreaks of cholera, according to doctors in the city. “In recent months we have seen a dramatic deterioration of our Vol 371 March 29, 2008

care system. Virtually everything to do with health is failing to perform at even the minimum expected standards”, said Douglas Gwatidzo, chairman of the Zimbabwe Doctors for Human Rights.

“The health-care system manages to stagger on thanks to the professionalism and dedication of locally-trained health-care workers...”
In the past few weeks, as the economic crisis deepens, the health service has undergone a dramatic deterioration, according to doctors across the country. Elective surgery has been abandoned in the central hospitals and even emergency surgery is often dependent on the ability of patients’ relatives to purchase drugs, suture materials, and supplies of blood from private sellers. The number of infants presenting with cerebral palsy is escalating because of failing obstetric services. Pharmacies stand empty and ambulances are grounded for want of fuel and spare parts. The deterioration of the healthcare system can be seen in the life expectancy statistics. 10 years ago a Zimbabwean was expected to live to 61 years. In 2007, that figure had dropped to 37 years for men and 34 years for women, representing the world’s lowest female life expectancy. Since the beginning of the HIV/AIDS crisis, Zimbabwe has halved its HIV prevalence from 33% a decade ago to 16% today, thanks to a reduction in the prevalence rate in the 20–25-yearold age group. However, some experts say this is not so much a result of good health care but because the high death rate from HIV/AIDS has convinced young people to delay sexual activity.

3 years ago the government started producing antiretroviral drugs and rolled out a national Prevention of Mother to Child Transmission Programme to over 1000 sites. The success of this intervention in reducing HIV infection at birth is largely credited with reducing the death rate of children under 5 years from 102 per 1000 infants in 1999 to 82 per 1000 infants in 2006 The government has been less successful in making antiretrovirals available on a regular basis. The estimated 90 000 people on antiretrovirals dwarfs the 300 000 thought to need them. Further controversy comes from charges that the limited drugs are given to army officers and officials of Mugabe’s ruling party, Zanu-PF. Hundreds of Zimbabweans now cross the border to Mozambique, where they can receive antiretrovirals, according to Mozambican authorities. Mugabe’s well founded reputation as an iron-fisted dictator has exacerbated the country’s health problems because major international donors do not want to prop up his regime. In 2004, the World Bank revealed that whereas other southern African countries

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Zimbabweans are crossing into Mozambique to get hold of antiretrovirals


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Zimbabwe’s hospitals are facing shortages of medical supplies

received on average US$150 million for HIV programmes, Zimbabwe received just $4 million. The Global Fund to fight AIDS, Tuberculosis and Malaria repeatedly rejected all but a few of Zimbabwe’s funding proposals, claiming that the applications were poorly crafted. A severe problem for the health system has been the exodus of Zimbabwe’s doctors, nurses, and other professionals. “Zimbabwe now has just one doctor for 12 000 people. There are only 800 doctors registered in the country”, said Gwatidzo. “Doctors are leaving on a weekly basis and nobody can blame them.” Shortages of latex gloves and other sterilised equipment puts professionals at risk of contracting HIV. A parallel decline in the education system means doctors and nurses cannot send their children to adequate schools. A further problem is that health professionals fear for their personal security in Zimbabwe’s volatile political situation. Some doctors and nurses have been threatened by Mugabe’s Youth Militia for allegedly providing medical treatment to opposition supporters who had been beaten by state forces. The result is that high numbers of skilled health professionals have left for South Africa, Botswana, the UK, the USA, Australia, and Canada. Only 25% of the 425 doctor posts in the state medical system are filled, according to official figures. Less than 13% of

provincial specialist posts are filled whereas just 22% of hospital specialist posts are occupied. “Zimbabwe’s health professionals are working under intense pressure and stress. They have too much to do, poor pay, a critical lack of supplies. What they are meant to do as doctors is just impossible”, said Peter Iliff, a doctor who has been working in Zimbabwe for 20 years. Zimbabwean health professionals abroad will only return when they are offered higher pay, stable financial conditions, realistic housing and car allowances, improved management of the government health system, and well defined opportunities for advancement, according to Iliff. Those health professionals who have remained in Zimbabwe are demanding to be heard. Last year, there was a strike by junior doctors, who largely run the hospital system, for adequate pay. 4 years ago the Zimbabwe Association of Doctors for Human Rights was founded and it has grown in numbers and in confidence to challenge the Mugabe regime. It is surprising that amid the country’s chaos and decline, Zimbabwe’s healthcare system still functions at all. Doctors and specialists say that proper funding could revive the country’s network of village health workers and rural and neighbourhood clinics. The health-care system manages to stagger on thanks to the professionalism and dedication of locally-trained health-care workers and the equitable health-care delivery system that was constructed between Zimbabwe’s independence in 1980 and 1995. As Zimbabwe’s economic meltdown spins out of control and the Mugabe government ceases to provide essential services, a tipping point has been reached and unless some dramatic intervention is made, one of the finest models of health care in the developing world may well collapse in ruins. For those who witnessed the evolution of Zimbabwe’s health service and knew it at its best, this

is an unmitigated tragedy, scarcely conceivable just a few years ago. The greatest part of the responsibility for the demise of this once proud institution can be laid squarely at the door of Mugabe and his selfdestructive regime. Those who know Zimbabwe and its people have no doubt that it will rise phoenix-like from the ashes of the current crisis. To do so rapidly will require massive external support. There is already talk of a Zimbabwean rescue package, with assurances of millions of dollars of emergency aid awaiting an acceptable resolution of the political crisis. But health-care officials warn of the destructive capacity of a sudden surfeit of funds. Especially, there is a fear that any new political dispensation may surrender Zimbabwe’s hardwon ownership of its development programme to the agenda of a well funded international donor agency. “It is important to emphasise how resilient Zimbabwe’s health-care system is. Despite everything it still manages to function, thanks to the sound community-based, preventive structure established in the 1980s and 90s. The western donors have starved this excellent system to try and punish Mugabe, but it is the people who are suffering. With adequate funding Zimbabwe’s health care could rebound, but it is important for it to remain directed by Zimbabweans and not become hostage to the agenda of a donor”, said Greg Powell, paediatrician who has worked in Zimbabwe for more than 30 years and who is the chairman of the Child Protection Society. Gwatidzo said he finds the decline of health care hard to believe. But he says that “the structures are still in place and I believe our health-care network could be revived. We are a dedicated lot and with funding and a stable situation I think we could turn things around fairly quickly. We are looking forward to that day.”

Andrew Meldrum Vol 371 March 29, 2008