DFID's Assistance to Zimbabwe - International Development Committee Contents

5  Health services

103. 43% of the UK's aid programme in Zimbabwe for 2009-10 is allocated to provision of basic services. DFID told us that: "The ability of the Inclusive Government to deliver quality basic services to its people is weak following years of under-investment and turmoil. The challenge of rebuilding basic services is massive and far exceeds the public purse available."[160] The DFID Minister's view was that there had been an improvement in the delivery of services, but that "huge challenges" remained. Some services were in place, but they were still "very basic" and a "much longer transition" needed to take place to bring "recognisable, good quality health, education and other services".[161] In this chapter we will focus on health services, including public health and the provision of sanitation and water. We discuss education in the next chapter on DFID's support for children.

104. World Vision told us that the Zimbabwean health system has been compromised by critical shortages of finance and declining infrastructure during the last 10 years. The morale of key health personnel had fallen due to poor pay and their inability to deliver health care because of shortages of diagnostics, drugs and support systems. A large number of health professionals had left Zimbabwe due to political and economic factors. This had resulted in a "critical shortage of human resources", especially in rural areas. Many rural clinics were no longer functioning and even in larger urban areas health care has suffered.[162]

105. In 2006 the World Health Organisation reported that life expectancy rates in Zimbabwe were amongst the lowest in the world: 37 years for men and 34 for women.[163] Dr Kibble highlighted the decline that had occurred—life expectancy in 1990 was 61 years—and that, given the unreliability of statistics in Zimbabwe, the current life expectancy rates may be lower than those officially quoted.[164]

106. DFID says that "health related services account for the vast majority of our basic services spending (about £25 million)."[165] It believes that its health programme has ensured that:

·  the health system in Zimbabwe is still largely functioning, with each clinic retaining a basic complement of staff, drugs and services;

·  access to anti-retroviral (ARV) treatment has continued to increase;

·  malnutrition rates for children remain below emergency levels;

·  contraceptive use has continued to grow and unmet need has shrunk; and

·  HIV prevalence has continued to decline.[166]

107. We visited Harare Hospital, Mpilo Hospital in Bulawayo and Kezi Maphisa District Hospital in Matabo, Matabeleland. The staff we met were clearly very professional and dedicated and the services we saw were very good. However, Mpilo and Harare hospitals are tertiary referral hospitals. They would be expected to offer the best health care in the country and are by no means the norm. Local services remain weak in many areas. People often have to travel long distances to access services which are inadequate and cannot always meet their needs.

108. The DFID Minister highlighted that one of the factors which contributed to the cholera epidemic in 2008 had been the deterioration in the health sector, caused by the lack of health staff. To help address this, DFID had introduced a Health Worker Retention Scheme which was contributing £1.9 million over two years. Other donors, including Australia, Denmark, the European Commission, UNICEF and UNFPA, now contribute to the scheme. An allowance is paid into health workers' bank accounts, to provide a direct incentive for them to go to work. The scheme has helped to increase the number of health workers from under 10,000 in December 2008 to over 26,000 in February 2009.[167] The Minister commented that, although it was worthwhile to provide direct assistance in this manner, the long-term solution would come from further economic stabilisation and a reduction in political instability.[168]

109. DFID is also supporting the supply of essential drugs following the identification in 2008 of a huge shortage of basic supplies and equipment. The Emergency Vital Medicines programme is now a two-year programme worth £11.5 million (with an additional £5 million provided in 2009-10), managed by UNICEF. DFID says that it is "the main vehicle for providing basic medicines and supplies" in Zimbabwe and has a particular focus on under-fives and women, and prevention and treatment of transmissible diseases. It is also supported by the European Commission, Australia, Canada, Ireland and the Netherlands. DFID says that the programme has been instrumental in ensuring that a basic supply of drugs and medical supplies are available at all 1,531 health facilities in Zimbabwe and especially at rural health centres and district hospitals.[169] Staff we met at Kezi Maphisa Hospital in Matabo told us about the difference it had made to their capacity to supply patients with the drugs they needed.

110. DFID support is making a significant difference to the availability and quality of health care available in Zimbabwe. The retention scheme for health workers is an important intervention which is making a contribution to addressing the lack of trained staff and supporting committed staff to continue to work in health care. The Vital Medicines programme has ensured that all health facilities in the country have basic drugs and medical supplies. We commend DFID's work in the health sector to date and recommend that it continue to give priority to supporting the rebuilding of health services.


111. DFID is providing nearly £40 million over the next five years to support HIV/AIDS programmes, focusing on behaviour change and access to anti-retrovirals (ARVs).[170] The HIV prevalence rate in Zimbabwe has declined from 18.1% in 2006 to 15.6% but is still one of the highest in the world.[171] There are over 62,000 deaths from HIV/AIDS each year. DFID is working with UNAIDS, WHO and other donors to support universal access to ARVs. However, Zimbabwe has more people living with AIDS without access to treatment than any other country.[172]

112. DFID has allocated £35 million to the Expanded Support Programme (ESP) (£6 million in 2009-10), a multi-donor funding mechanism which supports the National AIDS Strategy. ESP provided access to ARVs for more than 58,000 people in 2009.[173] It is implemented through UN agencies and is managed by a working group comprising government, donors, UN agencies and civil society. DFID told us that the ESP had demonstrated that it was "possible to support national policy and public services without passing money through the government and without becoming entangled in political debate."[174] An impact assessment of the ESP programme is planned for 2010. We saw this programme in operation at Kezi Maphisa District Hospital in Matabo and heard about the benefits it was bringing. We also saw a Voluntary Counselling and Treatment Centre in Bulawayo run by Population Services International which offered rapid testing and counselling, as well as group support.

113. William Anderson of Christian Aid endorsed DFID Zimbabwe's work on HIV/AIDS, saying that it was "a huge issue and DFID is right to concentrate on it."[175] Justin Byworth of World Vision highlighted that the social stigma around HIV/AIDS which existed some years ago was no longer evident. He said that programmes were effective, but the "need was huge."[176] The TUC told us that, due to the widespread prejudice in society, little attention had so far been paid to the need to prevent the spread of the pandemic among vulnerable groups, including sex workers, intravenous drug users, prison inmates and gays and lesbians. The TUC suggested that donor agencies like DFID should consider interventions targeted at vulnerable sections in society.[177]

114. The NGO Avert points out that Zimbabwe has historically received far less HIV/AIDS funding than other sub-Saharan African countries. For example, Zambia, which has a similar HIV prevalence rate, was reported in 2005 to receive around US$187 per HIV positive person annually from international donors; in Zimbabwe, the figure was estimated to be just US$4.[178] The Minister thought that the disparity "relates to the political situation in Zimbabwe and the ability of the international community to spend money effectively to tackle HIV/AIDS." As the economic situation stabilised, he believed that there would be greater opportunities for more to be done on healthcare, with HIV/AIDS remaining a priority. He said that the UK's assistance had been "absolutely pivotal" in helping to reduce HIV prevalence and the number of AIDS-related deaths.[179]

115. Male circumcision reduces the risk of HIV infection by about 60%. We saw DFID-supported programmes in two male circumcision clinics in Bulawayo and in Harare. This pilot programme was launched in mid-2009 and 3,000 men have so far been treated. In addition to the procedure, patients are provided with counselling and an HIV test. Once it is rolled-out, the programme aims to reach 80% of young men in the country in the next eight years, a total of three million people.[180] We were told this would cost $140 million, but would save over £3 billion in treatment costs.

116. Zimbabwe's HIV/AIDS rate is one of the highest in the world. The country and the international community face a huge task in trying to control the epidemic and provide support to HIV/AIDS sufferers. However, progress has been made and we commend DFID's work in this sector. The male circumcision programme we saw appears to be a very cost-effective method of reducing HIV transmission in a country with a prevalence rate as high as Zimbabwe's. We would encourage DFID to support the programme as it moves from the pilot to full implementation. The Expanded Support Programme (ESP) is fulfilling a vital function in provision of anti-retroviral treatment and broader treatment and care for people living with HIV and AIDS. We request that DFID shares the outcome of its impact assessment of ESP with us when it is available.

Maternal health

117. DFID has allocated £25 million over five years to maternal health services, and is spending £4.85 million in 2009-10.[181] DFID's programme includes a focus on women and newborn babies affected by HIV/AIDS, and access to family planning services. The rate of contraceptive prevalence increased from 55% in 1999 to 60% in 2006 and the rise has continued despite the decline in the economy and basic services.[182] Nevertheless, maternal health is still a serious concern with a maternal mortality rate of 880 per 100,000 live births.[183]

118. World Vision reported that half of pregnant women in rural areas were now delivering at home, with 40% of births taking place without a skilled attendant. User fees and other costs were said to be limiting women's access to services, as well as the shortage of trained staff and the need to travel long distances to reach services.[184] These are common contributors to poor maternal health outcomes as we highlighted in our 2008 Report on Maternal Health.[185] However, Justin Byworth believed that there had been some progress. He told us about a woman whom he met recently at an antenatal clinic in Zimbabwe. She contrasted her recent experience of childbirth with that two years previously: there had been a "real improvement" in terms of being able to give birth at a health centre and the subsequent immunisation and monitoring of her baby.[186]

Infant mortality

119. Dr Kibble reported that the latest estimates of infant mortality in Zimbabwe were 76 per 1,000 live births with under-five child mortality at 123 per 1,000 live births.[187] A donor-supported survey conducted in May 2009 showed a 20% rise in under-five mortality compared to 1990 rates.[188]

120. Malnutrition is the underlying cause of much child morbidity and mortality. The latest data indicated that a third of all children under five were chronically malnourished.[189] DFID agreed that malnutrition was the leading cause of infant mortality in Zimbabwe but said that it had not exceeded emergency levels in any district, partly because of the massive food aid programme which it and other donors had supported.[190] DFID published a Nutrition Strategy on 11 March 2010. We have long argued for this, given the devastating impact malnutrition has on children's health. DFID says that the "fight against malnutrition" will focus on the six countries which are "home to half of all undernourished children under five in the world." Zimbabwe is one of these focus countries.[191]

121. World Vision also pointed to HIV/AIDS, neonatal complications and infections, pneumonia and diarrhoea as key factors in the high levels of child deaths. Lack of accessibility to health care was another contributor. Children in rural areas and those in the poorest sections of the population are the worst affected and have least access to even basic health services. HIV positive children are particularly vulnerable.[192]

122. Maternal and child health are two key areas hit particularly hard by the decline in services in Zimbabwe. Many mothers and babies are already vulnerable due to HIV/AIDS, and shortages of health staff and facilities have compounded this. We recommend that, in response to this Report, DFID provide us with more details of its plans to provide further support to maternal and child health, to assist Zimbabwe to get back on track on these two central Millennium Development Goals.

123. Malnutrition is the leading cause of child deaths and ill health in Zimbabwe. Donors must continue to address this through food aid and longer-term nutrition interventions. DFID has recently published a Nutrition Strategy and has included Zimbabwe as one of the six countries where it will focus its efforts to tackle malnutrition. We would welcome more details, in response to this Report, on how the Strategy will guide DFID's work on child health in Zimbabwe.

Sanitation and water

124. In our 2007 Report on Sanitation and Water we emphasised that provision of sanitation and clean drinking water was essential to contain disease.[193] Oxfam says that the economic decline and reduced availability of clean water has increased the risk of water and sanitation related diseases in Zimbabwe: "water points have dried up, municipal water supply schemes have been shut down, wastewater systems blocked and general maintenance work has been abandoned." Alternate water sources, many of which are unprotected, have had to be found in both rural and urban areas. Oxfam stresses that many of the water, sanitation and hygiene-related issues in Zimbabwe are chronic ones, which require long-term solutions, as well as an "immediate public health humanitarian response."[194] 

125. DFID told us that it makes a significant investment in water, sanitation and hygiene programmes. It has been working with local communities and district technicians to install and maintain a minimum of 500 new water points each year. Rural schools and clinics benefit from sanitation provision, in addition to "particularly vulnerable households." The programme also supports health clubs. These have been shown to be effective in encouraging basic hygiene and health practices by working with village health workers and government environmental health technicians.[195] We visited a school in Sontala in Matabeleland where DFID had supported the provision of additional latrines as part of the PRP. We were told by the headmistress that the improved sanitation had protected the children from the worst effects of the cholera epidemic (see below). However, the school still did not have its own water borehole: it had to share the one used by the local community which was 1.5 kilometres away.


126. OCHA states that:

    In August [2008], one of the world's largest cholera epidemics in recent history broke out [in Zimbabwe]. It quickly expanded to all ten provinces, affecting 32,000 people and killing 1,500 by December. The epidemic was due to the lack of safe drinking water, inadequacy of sanitation, and declining health care infrastructure within an already overburdened healthcare system.[196]

World Vision highlighted that this outbreak differed from previous ones in that it was mainly urban and had a high fatality rate. In addition to the causes identified by OCHA, World Vision attributed the rapid spread of cholera to the Government's ban on NGOs operating in the country and a lack of knowledge about how cholera spreads, resulting in ineffective containment of the epidemic. It said that DFID's response to the outbreak had been "timelier than most donors and NGOs." However, DFID, along with other donors had been "slow to see the outbreak as a priority concern."[197]

127. William Anderson of Christian Aid agreed that the outbreak had been "an epidemic waiting to happen". He told us that "it had been talked about at various humanitarian agency co-ordination strategy working groups even before it broke out." He said that DFID should support local government and the community in improving water and sanitation services.[198] UNICEF believed that, without a major overhaul of Zimbabwe's social and health infrastructure, health crises like the cholera outbreak would recur.[199] Rob Rees of CAFOD agreed that there was a need, in the longer term, for a "major rehabilitation of the infrastructure."[200]

128. The Minister acknowledged this long-term need. He pointed to some DFID work that was already addressing water and sanitation issues, but emphasised that there was not a "clear long-term sector-wide plan on water and sanitation" on which DFID was leading. He was hopeful that, as progress was achieved on the political process in Zimbabwe, the donor community, in conjunction with the Government, could start to develop a plan for a "longer-term, more sustained investment in water and sanitation." However, at present, due to the demands of the current humanitarian situation, the balance of DFID's support would continue to focus on the delivery of basic services and "targeted assistance to support reforms in key ministries".[201]

129. We reiterate our previously stated view that sanitation and water are at the heart of development. We accept that long-term infrastructure projects, such as rehabilitation of sanitation and water systems, must wait for the humanitarian need to decrease and for the Government of Zimbabwe to be in a position to take the lead, supported by donors. However, DFID and its donor partners need to keep a clear focus on the contribution which poor sanitation and lack of clean water made to the scale of the cholera epidemic in 2008. They must ensure that health and humanitarian programmes do not lose sight of the importance of public health and hygiene in reducing the spread of disease.

160   Ev 56 Back

161   Q 54 Back

162   Ev 91 Back

163   Ev 50 Back

164   Ev 69 Back

165   Ev 56 Back

166   Ev 58 Back

167   Q 97 and Ev 95 Back

168   Q 97 Back

169   Ev 57-58 Back

170   "New dawn of hope for HIV help in Zimbabwe", DFID news story, 18 September 2009 Back

171   DFID, Annual Report and Resource Accounts 2008-09, Volume 2, p 167 Back

172   DFID, Zimbabwe: major challenges, available on DFID website at www.dfid.gov.uk/ Back

173   Ev 59 and Ev 95 Back

174   Ev 59 Back

175   Q 30 [Mr Anderson] Back

176   Q 30 [Mr Byworth] Back

177   Ev 83 Back

178   Avert, Introduction to HIV and AIDS in Zimbabwe, available at www.avert.org/aids-zimbabwe Back

179   Q 100 Back

180   "Circumcision: Zimbabwe's latest anti-HIV weapon", BBC News website, 26 February 2010, http://news.bbc.co.uk/ Back

181   Ev 60 Back

182   DFID, Annual Report and Resource Accounts 2008-09, Volume 2, p 167 Back

183   Zimbabwe : Key facts, DFID, http://www.dfid.gov.uk/ Back

184   Q 33 and Ev 91 Back

185   Fifth Report of Session 2007-08, Maternal Health, HC 66-I Back

186   Q 33 [Mr Byworth] Back

187   Ev 69 Back

188   Ev 91 Back

189   Ev 92 Back

190   DFID, Annual Report and Resource Accounts 2008-09 Volume 2, p 166 Back

191   DFID, The neglected crisis of undernutrition: DFID's strategy , March 2010. See also DFID Press Release "New drive to tackle malnutrition in 12 million children", 11 March 2010. The other focus countries are Bangladesh, Ethiopia, India, Nepal and Nigeria. Back

192   Ev 91 Back

193   Sixth Report of Session 2006-07, Sanitation and Water, HC 126-I, pp 3-4 Back

194   Oxfam's work in Zimbabwe in depth, available on Oxfam website at www.oxfam.org.uk/ Back

195   Ev 61 Back

196   UN OCHA, Annual Report 2008, p 95 Back

197   Ev 92 Back

198   Q 35 [Mr Anderson] Back

199   UNICEF press release , "Cholera cases in Zimbabwe near 100,000 as 'Twin Disaster' continues", 3 June 2009 Back

200   Q 35 [Mr Rees] Back

201   Q 107 Back

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