Zimbabwe: A nation's health in intensive care

A recent article in The Herald highlighted the demise of Harare Hospital. Quoting the superintendent, it depicted a picture of complete disintegration of a once prominent health facility. It was all the more credible because the government-owned press does not usually expose such failure of government institutions, and because any reader who has visited a government hospital in the past few months knows for himself or herself the heart-breaking catastrophes that occur daily. The superintendent told us that the lifts are not working, the mortuary fridges are dysfunctional and overflowing with corpses, the dialysis machines are not working, there are no surgical gloves, no bed-sheets, no drips, no medicines. The building itself is falling apart, with ceilings hanging and plumbing blocked. A scene of total dereliction and neglect.

But this is only the beginning of the story. What is happening in Harare Hospital is being repeated in every government hospital throughout the country and most of the clinics. It is not only Harare hospital which is in the intensive care unit. The entire health system is disintegrating before our eyes, and no one in government seems to have any interest or any plan for doing anything about it.

In the barely remembered days after Independence, ZANU-PF had a health policy - a very sensible one, inspired by egalitarian beliefs that health care was a fundamental right and should be made available to all. They inherited a system that had catered primarily for the white minority, with an emphasis on curative rather than preventative medicine. They recognised the fact that poor health stemmed more from poor social, economic and environmental conditions than from absence of western medical treatment. The high infant and child mortality rates and low life expectancy relative to those of white Zimbabweans, resulted from poverty, especially unsafe water and unsafe sanitary provisions combined with inadequate nutrition. The post-Independence health policy placed a focus on preventative health - protected toilets, safe water supplies, immunisation against childhood diseases, and family planning. Rural health centres, while providing curative treatments, were also to become centres for health education in the villages, through the training of village health workers; the general development of the economy would help to lift people out of poverty. Thus the mutually reinforcing relationship between poor health and poverty would be tackled from both ends - improvement in health services and reduction of poverty would go hand in hand.

Developments in the first few years of Independence were remarkable, and proved what a positive energy and dedication could achieve. In September 1980 the government announced a policy of free health care for everyone earning less than $150 per month; at a time when the minimum wage was $70, this included the vast majority of the people. Immunization campaigns were stepped up, especially in the rural areas, oral rehydration was introduced for diarrhoea, breastfeeding was promoted alongside childhood supplementary feeding, and improvements in water supply and sanitation. Contraceptive use was encouraged as a means to improving maternal health and reducing family size. Even the primary school syllabus was changed and textbooks were produced which introduced children to the "five killer diseases" as well as nutrition, and sanitation. The amount of funding for health increased from 4.6% of the total budget in 1979/80 to 5.9% of the budget in 1985/86.

As early as 1983 the results were already evident. Infant mortality fell from 120 per 1000 live births in 1980 to 83 in 1983 and 61 in 1989. Maternal mortality rates fell by 28% over the same years. The national average of underweight children dropped from 21% to 17.7% in 1984, and to 11% in 1988. Life expectancy rose from 56 in 1980 to 61 in 1990. These achievements were startling, bringing Zimbabwe very quickly to preside over one of the best health delivery systems in Africa, At the same time, economic growth assisted some families to rise out of poverty, as the GDP growth per annum averaged 4.3 in the 80's, with higher rates for the first half of the decade. The promise of health for all became a realisable dream.

The Human Development Index (HDI) is a measure of how developed a country is compared to others. It is calculated on the basis of four factors: life expectancy at birth, adult literacy levels, school enrolments, and GDP per capita. It is a very rough indicator, because it leaves out many significant factors, but it is used by the United Nations to give a general idea of levels of development. In 1980 Zimbabwe's level was .572, slightly higher than in 1975 when it was .547. By 1985 it had risen to .629. This compares to the 55 most developed countries, with indexes ranging from .886 to .734 in 1980.

But ZANU-PF held back from continuing with an aggressively preventative health care programme. More money continued to be poured into developing central hospitals and doctors continued to be trained with an urban-oriented curative based practice in mind. But if health standards throughout the country were not to fall back, poverty levels needed to continue to be controlled.

The peak was reached sometime after 1985. By 1990 the HDI had dropped back to .617, affected mainly by a significant drop in GDP per capita. The economy had begun to falter, held by the straight-jacket of government controls and growing corruption. The structural adjustment programme introduced in 1990 accelerated the growth of poverty. In 1990 the economy was still growing at the rate of 7% per annum, but by 1995 the rate was down to 0.2%. One of the conditions of continued balance of payments assistance from the IMF was that Zimbabwe reduce spending and introduce cost-recovery on social services. This meant that people would have to pay for health services. The government quite correctly resisted abandoning free health care, and it continued to be available to much of the rural population and some of the urban population, but as spending was cut, service provision deteriorated; often the specific care needed was either not offered or not adequate. Patients had no alternative in many cases but to seek treatment from the private sector or outside the country, something most could not afford. By 1996 30% of the population reported that they were having difficulty affording health care. Appeals for funds to pay for treatment abroad proliferated.

Into this already deteriorating situation marched a new disaster - AIDS. By 1990 the impact of AIDS was still in its early stages - the life expectancy rate was at its peak, although signs of what was to come were detectable in the slight rise of the infant mortality rate and the child mortality rate from their lowest levels in 1988 and 1989. Illness, rising death rates and growing poverty reversed the achievements of the 1980's. By 1995 the HDI was only .571, lower than in 1980, and by 2002, the last year for which we have figures, it was .491, substantially lower than in 1975, nearly thirty years earlier.

The combination of structural adjustment and AIDS played havoc with the health of Zimbabweans. AIDS is caused by a virus, but the virus spreads more rapidly in conditions of poverty and unemployment. The less money spent on the health sector, especially of a preventative nature, the more rapidly HIV will spread. The more it spreads, the more curative care is needed. Thus government was cutting spending on health just as more resources were needed.

Obviously, the ZANU-PF government cannot be held responsible for AIDS. It is a world-wide phenomenon, and particularly affects this region. But why has it spread more rapidly in some countries than others, Zimbabwe included? And why have we failed to control it, where others have succeeded? Various explanations have been given, many involving social behaviours and attitudes which would take a long time to change. It is indeed a tragedy that HIV AIDS arrived on the scene just at a point of weakness in our economic position. But that is what governments are for - to identify problems and devise solutions for dealing with them. Our government clearly bears responsibility in its failure to recognise and tackle the epidemic as an emergency requiring immediate, concerted responses and large injections of funds, whether from its own resources or from donors. Government simply refused to act. Testing of patients was not permitted even for the purpose of determining scientifically the extent of infection within the population. Instead, as late as 1990, there was an ostrich-like refusal to acknowledge the catastrophe and a public stance of "let's not be alarmist", when what was needed was the very loud sounding of a nation-wide alarm.

It was only after the 1990 election, when Timothy Stamps was appointed Minister of Health, that the danger was openly acknowledged, but even then little was done by government to tackle the problem. There was a lack of political will, a reluctance even to admit when a public figure died, that he or she had died of AIDS. Government's short term and medium term plans achieved little. In 1999 the President admitted that the government's response had been slow, and it was only in that year that a National AIDS Policy was announced and the National AIDS Council formed. The following year the AIDS levy was introduced.

The AIDS levy was intended to go directly to AIDS sufferers, their families and the orphans they left behind, a policy not without its political motivation. But by 2000 corruption had taken hold of every government and many private institutions; the criteria for disbursement of the funds were imbued with political preference; the policy of relying on local committees was derailed by lack of capacity and clear corruption; enormous amounts were spent on salaries, perks and endless workshops, and it has not surprised anyone that the bulk of the funds never reached the intended beneficiaries. Meanwhile the health services, which had an additional burden to bear, were not being allocated the required funds. From an annual spending at a rate of $58 per capita in 1990/91, it collapsed to $36 in 1995/96, and never recovered adequately to deal with the crisis. Programmes which survived were generally provided by donors or were donor-funded, such as immunization, family planning, construction of toilets, and later the New Start counselling and testing for AIDS. AIDS awareness and education was largely carried out by NGOs after a foreign-funded attempt to integrate it into the school curriculum proved largely ineffective.

Meanwhile, health indicators were telling the story: life expectancy fell from a peak of 61 years in 1990 to 51.8 in 1995, and 38.2 in 2001. The child mortality rate climbed from 80 per thousand live births in 1990 to 123 in 2002, making it the third highest in the world. The number of T.B.cases multiplied by 5 times in the years 1990-2000. Zimbabweans were living short lives, experiencing poor health and failing to access medical care.

It is not easy, from the morass of statistics to determine what is the simple effect of AIDS and what results from the failure of the health system. AIDS and the failure of health policy are two sides of the same coin. Government simply neglected to respond. Instead of examining policies carefully to determine what to do about the devastating social effects of the structural adjustment programme, and devise a rapid response to the problem of AIDS, government dilly-dallied and allowed the health services to unravel before their eyes. Far from increasing health expenditure to meet the challenge, government looked aside as the catastrophe gained momentum, and spent its money on the army, the police, and propping up corrupt and dysfunctional parastatals. When doctors and nurses began to demand salaries commensurate with their skills and their importance to the nation, government, in their usual arrogant fashion, ignored them until they staged devastating strikes. Instead of treating the situation as a national health emergency, government responded with heavy-handed violence, tear-gassing nurses and arresting junior doctors. In fact, they had no idea how to deal with the complex problems of a declining GDP, galloping death rate, and rapidly spreading discontent. In the face of growing political opposition, all attention was focussed on repression, and spending directed towards the security apparatus.

While most Zimbabweans have few employment options, doctors and nurses do not have to put up with poor conditions and low salaries; they can leave. The exodus of skilled personnel which began in the mid 90's affected none so much as the medical professionals. Few professionally trained people want to work without the tools of their trade, watching day after day as people die who could be saved. Even the most committed will eventually give up. Their skills being readily marketable almost anywhere in the world, they flooded out of the country. Opportunism gained a hold on the profession. Medical training had always been highly popular among the young, but now there was a rush to enter medical school or nursing training, as the preferred means of leaving Zimbabwe. And standards of service, as of facilities, continued to deteriorate. By 1998, per capita health spending was lower than it was at Independence.

By February 2000, the health of Zimbabweans was in a parlous state while the delivery system staggered, starved of funds, and rapidly losing skilled staff. But government chose this moment to deal the final death blow. The farm invasions, calculated to revive ZANU-PF's long ailing popularity, took the economy into freefall. In that year alone, the economy shrank by 8.2%. By 2002 the shrinkage was another 14.5%, followed by 13.9% in 2003. By the beginning of 2005, the economy was only half the size of what it had been five years earlier. In a frantic race to boost the "new farmers'" capacity to produce food, before famine set in, and to maintain control of government, ZANU-PF made sure that funding was diverted to support agriculture, and health provision was ignored. As hospitals and eventually the private medical sector haemorrhaged doctors, nurses, specialists, pharmacists, physiotherapists, and all sorts of technicians, government had no solutions but to search for personnel from other countries. While complaining that Britain and the U.S. were "stealing" our doctors, we proceeded to "steal" doctors from the DRC, at higher salaries then we were prepared to pay to our own.

But the real crime was to destroy what had been a faltering but ultimately functioning economy. From 2000, poverty levels shot up. It is well known, and was clearly acknowledged by ZANU-PF after Independence, that poverty has a direct bearing on the health of people and is one of the strongest factors in the prevalence of various infectious diseases, including HIV-AIDS. Since 2000, as the economy shrank by half, employment levels have dropped by almost the same amount. The unemployed become cross-border traders, gold panners, prostitutes, all of which are occupations which expose people to squalid living conditions, poor sanitation, contaminated water, high-risk sexual relationships, and disease, especially HIV infection. Thus while poverty increases, disease levels multiply, but treatment has declined as the health services no longer provide. The result is plain for all to see in the expanding cemeteries, the growing number of orphans, lower development indexes, and lower life expectancies.

But the worst was still to come. In a nation where there are high levels of sickness and low levels of health care availability, government policies then contrived to deprive poor, unwell people of food. The dislocations of the land invasions and displacement of commercial farmers could not take place without affecting food production. Government attempted to deny that this would occur, but did allow donor agencies and NGOs to import and distribute food in 2002. By 2003 there were increasing disruptions in the distribution of the food aid as government sought to use it for political control over the people. By 2004, when it was clear that not enough food was being produced by the "new farmers", government hid behind deliberate lies, pretending there was enough food and refusing to allow further imports. Government actually rejected donated food which was offered and used its own now scarce funds to secretly import, so it could retain control of food supplies. The result has been disastrous for the health of the nation. We will never know how many mothers and teenage girls contracted HIV infections because they were forced to prostitute themselves in exchange for food for their children or younger siblings. We will never know how many Zimbabweans died of AIDS because they were weakened from lack of sufficient food. Thousands of fathers, and even more mothers, could have survived and looked after their families for many more years had they had sufficient food. And yet, the food was there, or could have been made available, but was denied them because ZANU-PF wanted to maintain the evil fiction that food had been produced when it hadn't.

With all attention focussed on a violent solution to a land problem that could easily have been resolved peacefully, ZANU-PF forgot about health. No money was available for salaries, equipment, drugs, or the necessary ingredients of a health care system. By 2003, at least 1,820,000 Zimbabweans were living with HIV/AIDS; more than 500 were being newly infected every day, and in that year alone 171,000 died of the killer disease. But by 2003 expenditure on health had declined from US$ 25 per capita in 1995 (already lower than in the 1980's) to under US$ 10. By the first quarter of 2004, government services had only 45% of the doctors needed; 55% of the nurses, 48% of radiographers and 9% of the required pharmacists.

It is in this context that we should not be surprised when we hear that Harare Hospital is in the intensive care unit. So is the entire health system. In the years 1995-2001 - that is, even before the terrible collapse of the last four years - the proportion of the population with access to health care decreased by a staggering 41%. In the provinces of Mashonaland West, Manicaland and Matabeleland South the decrease was 60%. Who can tell what has happened since then? One of the indicators of the collapse is that statistics become more and more difficult to obtain and to verify. Not only is there a politically-motivated reluctance to release them, because they might reveal an ugly truth, but frequently they are simply not collected. Zimbabwe's health care system has dropped into a black hole where we can see only misery and suffering but we can no longer measure its extent.

And what is government's reaction? Knee-jerk. Throw money at it. Money, of course, that we don't have, because all available resources are being diverted to revive a once-thriving agriculture, now wilfully destroyed, to import weapons when we have no war, to pay the militia to terrorise the population, and to enable the secret police to sniff out the discontented. Within a week of the report about Harare Hospital, the Minister of Health had announced that $100 billion would be spent to resuscitate it. Why does our government assume that everything can be corrected with money? Are we going to print enough money to give billions to every hospital and every clinic? Or is it only Harare Hospital that will be saved from oblivion? What are we going to do about the hundreds of thousands who will die of AIDS in the next two years? Beg some more anti-retrovirals from donor agencies when neither the delivery system nor the social system can use them effectively? Or are we going to starve them all so that we don't have to worry about them any more? A government that starves its own sick people in order to make political capital is an insult to humanity - as is the whole sad story of Zimbabwe's health system in the past fifteen years.

A health system is organically integrated with the society which it serves. ZANU-PF recognised in the beginning that one of the key factors in raising the health standards was the reduction of poverty.

That fact has not altered, but ZANU-PF's understanding of it tragically has. More drugs and more money for hospitals are not going to restore us to the proud position we were in fifteen years ago. AIDS will not be conquered by antiretrovirals as long as people are living in destitution and weak from hunger. Yes, vast amounts of money will need to be committed. But we need a return to the fresh enthusiasm and dedication that we have lost. A whole rethink and development of policies which will put the nation on the road to economic recovery is necessary, so that poverty can be rooted out. Then a comprehensive health policy which caters for improved living conditions and changed social attitudes as well as curative treatment of disease will need to devised. These new approaches will come from within Zimbabwe, but they require a government that has constructive imagination, genuine concern for the well-being of its people, a determination to improve their lives rather than cling to power, and a readiness to work with willing donors rather than insulting them. Only then will Harare Hospital be removed, along with the entire nation, from the intensive care unit.