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."
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".
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.
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.
Dr Kibble highlighted the decline that had occurredlife
expectancy in 1990 was 61 yearsand that, given the unreliability
of statistics in Zimbabwe, the current life expectancy rates may
be lower than those officially quoted.
106. DFID says that "health related services
account for the vast majority of our basic services spending (about
It believes that its health programme has ensured that:
health system in Zimbabwe is still largely functioning, with each
clinic retaining a basic complement of staff, drugs and services;
to anti-retroviral (ARV) treatment has continued to increase;
rates for children remain below emergency levels;
use has continued to grow and unmet need has shrunk; and
prevalence has continued to decline.
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.
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.
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.
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).
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.
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.
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.
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
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."
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
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.
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.
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.
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.
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.
117. DFID has allocated £25 million over five
years to maternal health services, and is spending £4.85
million in 2009-10.
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.
Nevertheless, maternal health is still a serious concern with
a maternal mortality rate of 880 per 100,000 live births.
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.
These are common contributors to poor maternal health outcomes
as we highlighted in our 2008 Report on Maternal Health.
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.
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.
A donor-supported survey conducted in May 2009 showed
a 20% rise in under-five mortality compared to 1990 rates.
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.
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.
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.
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.
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.
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."
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.
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 , 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
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."
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.
UNICEF believed that, without a major overhaul of Zimbabwe's
social and health infrastructure, health crises like the cholera
outbreak would recur.
Rob Rees of CAFOD agreed that there was a need, in the longer
term, for a "major rehabilitation of the infrastructure."
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".
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
Q 54 Back
Ev 91 Back
Ev 50 Back
Ev 69 Back
Ev 56 Back
Ev 58 Back
Q 97 and Ev 95 Back
Q 97 Back
Ev 57-58 Back
"New dawn of hope for HIV help in Zimbabwe", DFID news
story, 18 September 2009 Back
DFID, Annual Report and Resource Accounts 2008-09, Volume 2,
p 167 Back
DFID, Zimbabwe: major challenges, available on DFID website
at www.dfid.gov.uk/ Back
Ev 59 and Ev 95 Back
Ev 59 Back
Q 30 [Mr Anderson] Back
Q 30 [Mr Byworth] Back
Ev 83 Back
Avert, Introduction to HIV and AIDS in Zimbabwe, available
at www.avert.org/aids-zimbabwe Back
Q 100 Back
"Circumcision: Zimbabwe's latest anti-HIV weapon", BBC
News website, 26 February 2010, http://news.bbc.co.uk/ Back
Ev 60 Back
DFID, Annual Report and Resource Accounts 2008-09, Volume 2,
p 167 Back
Zimbabwe : Key facts, DFID, http://www.dfid.gov.uk/ Back
Q 33 and Ev 91 Back
Fifth Report of Session 2007-08, Maternal Health, HC 66-I Back
Q 33 [Mr Byworth] Back
Ev 69 Back
Ev 91 Back
Ev 92 Back
DFID, Annual Report and Resource Accounts 2008-09 Volume 2,
p 166 Back
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
Ev 91 Back
Sixth Report of Session 2006-07, Sanitation and Water,
HC 126-I, pp 3-4 Back
Oxfam's work in Zimbabwe in depth, available on Oxfam website
at www.oxfam.org.uk/ Back
Ev 61 Back
UN OCHA, Annual Report 2008, p 95 Back
Ev 92 Back
Q 35 [Mr Anderson] Back
UNICEF press release , "Cholera cases in Zimbabwe near
100,000 as 'Twin Disaster' continues", 3 June 2009 Back
Q 35 [Mr Rees] Back
Q 107 Back