Zimbabwe's once proud achievements in health have been undermined over the past 20 years by increasing poverty, bad governance, poor economic policies, widespread HIV/AIDS, and a weakened health system. A Viewpoint published Online First and an upcoming edition of the Lancet states the priorities that the country must address to improve its currently horrendous health indicators. The Viewpoint is written by group of doctors with expert knowledge of Zimbabwe, led by Dr Charles Todd, former chairman, University of Zimbabwe School of Medicine, and Westongrove Partnership, Wendover Health Centre, Aylesbury, UK, and colleagues.
Zimbabwe's Government of National Unity (GNU), established on Feb 13, 2009, has instigated at 100-day recovery plan, which has seen the country's health sector gradually begin operating again, with doctors and nurses returning to posts and health centres once again operational. The decline in health indicators over the past three decades has been immense. 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 199014 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 fluids, and other supplies.
The authors believe priority must now go to the re-establishment of essential services such as effective emergency obstetric care in all districts. This challenge will mean refocusing the work of central and provincial hospitals to providing secondary health care. Furthermore, they suggest the following priorities for restoring Zimbabwe's health service and health training institutions:
- The Ministry of Health, together with leading civil society groups, UN agencies, and donors, should evaluate implementation of the 100-day action plan and craft a budgeted, medium-term health-care recovery plan including priority actions to tackle Zimbabwe's major health issues.
- The Health Services Fund—originally established in the 1990s to retain user fees at local level and later used for increased donor support to district health services—should be resuscitated. This would provide directly accessible funds for district health teams to maintain effective health services.
- The training of specialist mid-level workers (ie, clinical officers and nurse anaesthetists) should be rapidly restored and expanded, taking the lead from Malawi and Mozambique where such workers perform key frontline health functions. The existing health workforce cannot meet Zimbabwe's needs so any resistance to specialist mid-level workers from professional associations must be overcome.
- The return of health professionals to Zimbabwe should be encouraged, but without disadvantaging those who have remained.
- The Ministry of Health should continue to promote an inclusive and cooperative ethos. Voluntary organisations and missions should be further supported. Civil society organisations involved in health should be formally recognised, and their advocacy of human rights and monitoring of donor funds encouraged.
- The political will to tackle the deep-rooted culture of violence and impunity should be nurtured and translated into legislation, including the establishment of a Healing and Reconciliation Commission and permitting human rights' organisations to run programmes for community-based mental health care of survivors of organised violence.
The authors conclude: "Success in the 1980s was built on widespread community mobilisation accompanying a protracted struggle for human rights. Since then, Zimbabweans have been systematically deprived of these rights, including the right to health. A new opportunity now exists to rebuild the health-care system; its success will be contingent on firmly re-establishing the principles of social justice, equity, and public participation."
Dr Charles Todd, former chairman, University of Zimbabwe School of Medicine, and Westongrove Partnership, Wendover Health Centre, Aylesbury, UK. Contact via e-mail. E) chas.todd@nhs.net
For full Viewpoint, see: http://press.thelancet.com/zimbfinal.pdf
Journal
The Lancet