ZADHR News 3 What is the way forward for health in Zimbabwe? (continued from page 2) medicines or closure of treatment facilities have been unable to re-establish treatment.5 In 2005, Zimbabwe was losing an estimated 20% of its health-care professionals every year; 18 000 nurses have left since 1998.18 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.5 Many health workers witnessed violence and some were harassed for treating victims of violence. Health training in Zimbabwe has suffered 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 filled; Bulawayo’s new medical school faces even greater staff shortages. Nursing and midwifery schools struggle with 60% of nurse tutor posts vacant.7 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.19 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 reestablishing well-managed primary health-care programmes within functioning district health systems, providing costeffective essential services such as immunisation, integrated care of sick children, nutrition programmes, maternity services, improved management of tuberculosis, malaria, and sexually transmitted infections (including HIV/AIDS), and basic curative care including surgery. Inter-sectoral work addressing determinants of health and involving agriculture, education, water, and sanitation should again become a core activity of district health systems. Zimbabwe’s macroeconomic situation is critical with a national debt exceeding $3 billion.1 Therefore, initially funds for the health sector should come from donors. The UK, the European Union, the USA, other bilateral donors, the Global Fund, and UN agencies are all providing substantial funding that now includes retention allowances for health workers, essential drugs, vaccines, laboratory supplies, and HIV commodities. However, a substantial increase in funding will depend on clear progress of political and human rights, improved transparency, and an end to economic mismanagement and corruption. Implementation of the 100-day health action plan7 has led to the return to work of health workers and health facilities are functioning again. There is a renewed sense of hope. 2 million children were vaccinated in June, 2009, through national immunisation days. The cholera epidemic is finally under control.17 The 50% decline in HIV/AIDS prevalence over the past decade should soon translate into reduced AIDS-related deaths.4 Although mortality of children younger than 5 years has increased, it remains low compared with that of other countries with similar GNI. 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. Presently in the public sector, specialised services such as cancer care, dialysis, and advanced imaging are unaffordable. An early policy of the GNU was to impose substantial foreign-currency user fees at government hospitals6 to generate funding for health services. Accepting that cost-recovery initiatives frequently disadvantage the poorest people,20 the Ministry of Health is now reviewing such fees.7 Although Zimbabweans inside and outside the country are more optimistic now, many believe that tangible, universal health and social improvements will only follow radical change to the current political dispensation. Recent South African humanitarian assistance worth $30 million, which was meant for agriculture inputs, went mainly to areas loyal to ZANU-PF.21 The new Minister of Health has to establish greater accountability and commitment within the public health service and revitalise the former sense of collective responsibility among health workers. Zimbabwe built a strong human resource base after independence, and the expertise and dedication of the health workforce was key in achieving and sustaining Zimbabwe’s health service. Challenges that must be addressed include: attracting back health workers who have emigrated, improving the role of mid-level health workers such as clinical officers, ensuring the quality of health training, and providing continuing education to the existing workforce. During the recent political upheavals, civil society groups were fundamental in highlighting health and human rights abuses. During Operation Murambatsvina (drive out trash) in 2005,22 the effects of evictions in Zimbabwe were documented by civil society organisations; their reports and satellite pictures appeared on websites around the world, resulting in an international outcry at this destruction. Consequently, the UN appointed a Special Rapporteur to investigate the situation.23 Similarly, the cholera epidemic was predicted by a residents’ association monitoring water supplies and refuse disposal. Human-rights organisations, such as the Zimbabwe Association of Doctors for Human Rights rather than professional groups, such as the Zimbabwe Medical Association, emphasised the serious breakdown in health services. The Community Working Group on Health, a network of 35 organisations promoting equitable and accessible health care through local community mobilisation,24 has remained active throughout. These groups should be full and active partners in remodelling the health system. There are examples of doctors who help poor people by running clinics from their homes and dispense drugs donated by friends abroad. This spirit of volunteering is crucial to encourage bridge-building with excluded communities. Communities need a mandate and resources to actively participate in primary health-care activities, and thus hold government accountable for the quality of services. We therefore suggest the following priorities for restoring Zimbabwe’s health service and health training institutions: