What is the way forward for health in Zimbabwe

Zimbabwe’s Government of National Unity (GNU), established on Feb 13, 2009, faced immense challenges: a collapsed economy with 94% of the population without a job and almost 50% needing food aid; a severe cholera epidemic; HIV/AIDS prevalence of more than 15% in adults aged 15–49 years; and a collapsed health system. The GNU responded to the issues of the health sector by holding an inclusive summit and adopting an ambitious 100-day recovery plan for the health sector. Here, we describe the recent health crisis and its causes, and make proposals for an eff ective and sustainable health system. Zimbabwe was once a beacon of hope in Africa, improving health tremendously after independence in 1980. A declining national income, a huge national debt, economic structural adjustment, recurrent droughts, widespread HIV/AIDS, and a weakening health system all contributed to the deterioration of Zimbabweans’ health since 1990. Between 2000 and 2005, the gross national income (GNI) per head declined by 54%. The latest estimate of US$340 places Zimbabwe among the world’s poorest countries: all the income gains of the past 56 years have been wiped out. Economic decline has driven the exodus of Zimbabweans, with over 3 million of the total population of 13·5 million estimated to be living outside the country; the funds remitted by them are the main source of income for many families. For those having no access to external funds the situation is dire. Between 1990 and 2006, life expectancy at birth plummeted from 62 to 43 years, mostly from increased young adult mortality from HIV-related conditions. Mortality rates of children younger than 5 years and infants rose from 77 and 53 per 1000 livebirths in 1992 to 82 and 60 in 2003, respectively. Maternal mortality rose from 168 per 100 000 births in 1990 to 725 per 100 000 in 2007. Tuberculosis incidence increased from 136 per 100 000 in 1990 to 557 per 100 000 in 2006. These indicators are related to the high prevalence of HIV/ AIDS, which was estimated at 26% in 2000 in adults aged 15–45 years but declined to 15·3% by 2007. In 1994, 80·1% of children aged 12–23 months had received all basic vaccines compared with 74·8% in 1999 and only 52·6% in 2006–07. By early 2009, hospitals in the country were hardly operating, with massive shortages of essential medicines and supplies. Although most hospitals are now functioning again, shortages are still commonplace and patients usually need to buy medicines, intravenous fl uids, and sutures. Women delivering in rural clinics must bring candles, cotton wool, methylated spirit, gloves, and even fresh water. The physical infrastructure of most government health facilities is decrepit, and ambulances sparse. The recent cholera outbreak further exposed Zimbabwe’s collapsed infrastructure and its health system. Between August, 2008, and July, 2009, 98 591 suspected cholera cases were reported, including 4288 deaths. The epidemic resulted from the breakdown of urban water and sanitation systems, leading to contamination of piped water and shallow wells. The case-fatality rate peaked at almost 6%, greatly exceeding the 1% WHO norm, indicating the weakened health system and poor access in rural areas. Total health expenditure per head fell by 56% between 2000 and 2005 to $21, of which $9 was government expenditure. External funding contributed 21% of total health spending, a low proportion compared with that in most African countries. Under the previous government, which was led by Zimbabwe African National UnionPatriotic Front (ZANU-PF) party, bilateral donors channelled funds to specifi c activities such as HIV programmes and family planning. Therefore, 58% of currently married women use modern contraceptive methods, and about 100 000 people were receiving antiretroviral treatment by the end of 2007. However, antiretroviral treatment coverage at 17% is the lowest of any country in southern Africa, with an estimated 570 000 people needing treatment. Furthermore, HIVpositive patients displaced by political violence and those aff ected by stock-outs of common AIDS medicines or closure of treatment facilities have been unable to reestablish treatment. In 2005, Zimbabwe was losing an estimated 20% of its health-care professionals every year; 18 000 nurses have left since 1998. Although some heroically continued to work for minimal rewards, by the end of 2008 many had stopped working. By this time, a government doctor’s salary had fallen to less than $1 per month. Many health workers witnessed violence and some were harassed for treating victims of violence. Health training in Zimbabwe has suff ered badly and the country’s principal medical school—the College of Health Sciences of the University of Zimbabwe in Harare—closed from November, 2008, to May, 2009. Only 40% of academic posts are fi lled; Bulawayo’s new medical school faces even greater staff shortages. Nursing and midwifery schools struggle with 60% of nurse tutor posts vacant. Disregard for human rights has long featured in Zimbabwe’s history. After the elections in March, 2008, thousands of people were beaten or tortured in an attempt to subdue support for the opposition. Political abductions and intimidation continue despite the establishment of the GNU. National recovery cannot take place without addressing human rights and ending the culture of impunity. To restore Zimbabwe’s health sector, the priority must be to meet the population’s most urgent health needs by Lancet 2010; 375: 606–09