ZADHR News 4 What is the way forward for health in Zimbabwe? (continued from page 3) • • • • • • The Ministry of Health, together with leading civil society groups, UN agencies, and donors, should evaluate implementation of the 100-day action plan7 and craft a budgeted, medium-term health-care recovery plan including priority actions to tackle Zimbabwe’s major health issues. The focus should be the re-establishment of district health systems based on primary health care. International advocacy is needed to rapidly secure substantial resources of the Global Fund to fight AIDS, tuberculosis, and malaria already earmarked for Zimbabwe25 and other global health funds. 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 Health Services Fund should be jointly managed by the Ministry of Health and donors to ensure its probity and accountability. Donor funding will start flowing for strengthening the health system, and, with the joint planning process, catalyse a sector-wide approach in health. 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.26,27 The existing health workforce cannot meet Zimbabwe’s needs so any resistance to specialist mid-level workers from professional associations must be overcome. Similarly, the once successful Community Health Worker programme needs reorganisation and expansion to ensure community coverage.28 The return of health professionals to Zimbabwe should be encouraged, but without disadvantaging those who have remained. Diaspora groups, including regional and overseas institutions, already supporting training institutions and health service provision, should be part of a dialogue with the Government and Zimbabwean health professionals. The Government must remove bureaucratic hurdles to the return of professional Zimbabweans, such as the timeconsuming and costly registration process. 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. 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. 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. References 1 UNDP. Comprehensive economic recovery in Zimbabwe. A discussion document. UNDP Zimbabwe, 2008. http://www.undp.org.zw/images/stories/Docs/ Publications/CompEconoRec2008.pdf (accessed March 2, 2009). 2 WFP. Major food appeal for Zimbabwe as WFP relief distributions begin. World Food Programme 2008. http://www.wfp.org/node/131 (accessed March 2, 2009). 3 Chambers K. Zimbabwe’s battle against cholera. Lancet 2009; 373: 993–94. 4 WHO, UNAIDS, UNICEF. Epidemiological factsheet on HIV and AIDS, Zimbabwe. 2008 Update. Geneva: UNAIDS/WHO, 2008. 5 Physicians for Human Rights. Health in ruins. A man made disaster in Zimbabwe. Washington DC: PHR, 2009. 6 Shoko B. Zimbabwe: Stakeholders moot 100 days to improve health. The Standard (Zimbabwe). March 14, 2009. http://www.thezimbabwestandard.com/index.php? option=com_content&view=article&id=19925:stakeholders-moot-100-days-toimprove-health&catid=31:zimbabwe-stories&Itemid=66 (accessed July 24, 2009). 7 Ministry of Health and Child Welfare. Getting the Zimbabwe health care system moving again. Health action plan for the first 100 days. March–June 2009. Harare: Government of Zimbabwe, 2009. 8 World Bank. World development indicators database. World Bank, 2008. http:// ddp-ext.worldbank.org/ext/ddpreports/ViewSharedReport? &CF=1&REPORT_ID=9147&REQUEST_TYPE=VIEWADVANCED&HF=N& WSP=N (accessed July 17, 2009). 9 World Bank. Gross national income per capita 2007, Atlas method and PPP. World Bank, 2008. http://siteresources.worldbank.org/DATASTATISTICS/Resources/ GNIPC.pdf (accessed April 22, 2009). 10 Clemens M, Moss T. Cost and causes of Zimbabwe’s crisis. Washington DC: Center for Global Development, 2005. http://www.cgdev.org/content/publications/ detail/2918/ (accessed April 28, 2009). 11 Foreign and Commonwealth Office (UK). Country profile Zimbabwe. June, 2009. http://www.fco.gov.uk/en/about-the-fco/country-profiles/sub-saharan-africa/ zimbabwe (accessed July 23, 2009). 12 WHO. World Health Statistics 2008. Geneva: WHO, 2008. 13 Central Statistical Office (CSO) Zimbabwe and Macro International Inc. Zimbabwe demographic and health survey 2005–6. Calverton, Maryland: CSO (Zimbabwe) and Macro International, 2007. 14 Mbizvo MT, Fawcus S, Lindmark G, Nyström L. Maternal mortality in rural and urban Zimbabwe: social and reproductive factors in an incident case-referent study. Soc Sci Med 1993; 36: 1197–205. 15 Ministry of Health and Child Welfare. Maternal and perinatal mortality study 2007. Harare: Government of Zimbabwe, 2009. 16 WHO. Global, tuberculosis, control 2008—surveillance, planning, financing. World Health Organization, 2008. http://whqlibdoc.who.int/ publications/2008/9789241563543_eng.pdf (accessed March 4, 2009). 17 Ministry of Health and Child Welfare, WHO. Daily cholera update and alerts, 9 July 2009. http://www.who.int/hac/crises/zwe/sitreps/ zimbabwe_cholera_update_9july2009.pdf (accessed July 14, 2009). 18 Chikanda A. Medical leave: the exodus of health professionals from Zimbabwe, Southern African Migration Project Series, 2005. 19 Human Rights Watch. Bullets for each of you. State sponsored violence since Zimbabwe’s March 29 elections. New York: Human Rights Watch, 2008. http:// hrw.org/reports/2008/zimbabwe0608/ (accessed Aug 19, 2008) 20 Gilson L, McIntyre D. Removing user fees for primary care in Africa: the need for careful action. BMJ 2005; 331: 762–65. 21 Thornycroft.P. Wasted SA Aid. Sunday Independent (South Africa). Feb 8, 2009. 22 Kapp C. Operation ‘Restore Order’ wreaks havoc in Zimbabwe. Lancet 2005; 366: 1151–52. 23 Tibaijuka AJ. Report of the Fact-Finding Mission to Zimbabwe to assess scope and impact of Operation Murambatsvina by UN Special Envoy on Human Settlement Issues in Zimbabwe. New York: United Nations, 2005. http://www.un.org/News/dh/infocus/zimbabwe/zimbabwe_rpt.pdf (accessed March 4, 2009). 24 Mubaira C. Community Working Group on Health. http://www.phmovement.org/iphu/files/CWG_Compressed(Caroline).ppt (accessed April 26, 2009). 25 The Global Fund to fight AIDS, Tuberculosis and Malaria. Portfolio of grants – Zimbabwe. http://www.theglobalfund.org/programs/portfolio/?countryID=ZIM&lang=en (accessed May 9, 2009). 26 Thetard R, Macheso A. Clinical Officers in Malawi. SA Fam Pract 2004; 46: 32. 27 Pereira C, Cumbi A, Malalane R, et al. Meeting the need for emergency obstetric care in Mozambique: work performance and histories of medical doctors and assistant medical officers trained for surgery. BJOG 2007; 114: 1530–33. 28 Haines A, Sanders D, Lehmann U, et al. Achieving child survival goals: potential contribution of community health workers. Lancet 2007; 369: 2121–31.