ZIMBABWE: The long road to recovery
User fees are a barrier for many patients
Harare, 11 May 2009 (IRIN) - From his office in the vast, run-down health ministry building in Harare, the capital, Dr Henry Madzorera, Zimbabwe's new health minister, has the unenviable task of resuscitating a public health system crippled by the country's prolonged economic crisis.
A lack of equipment, drugs and salaries precipitated a health worker strike in November 2008 that forced most hospitals to close for several months just as a cholera epidemic, which has so far claimed over 4,200 lives, was sweeping the country.
"We've got 101 priorities," said Madzorera, a member of the former opposition party, the Movement for Democratic Change. "But the burning, immediate ones are the human resource issue. If we can get our health care workers back and remunerate them properly, that would be half the job done."
Most health workers have now returned to work and are receiving monthly US$100 allowances in lieu of salaries so devalued by inflation as to have become virtually worthless.
The allowances are largely funded by donors, but Madzorera said the government expected to take them over and gradually increase them in the next 12 months.
Hospitals have reopened and although far from fully operational, "Things are improving," said Amon Siveregi, head of the Zimbabwe Health Workers Association and an anaesthetist at Parirenyatwa Hospital, the largest referral facility in Harare.
Stocks of equipment and drugs are gradually being replenished, and machinery repaired. "We just want to help each and every patient like we used to," said Siveregi.
ARV programmes largely uninterrupted
Thanks in large part to international donors including the Global Fund to Fight AIDS, Tuberculosis and Malaria, the UN Children's Fund (UNICEF), and the Clinton Foundation, HIV/AIDS programmes have weathered Zimbabwe's health crisis better than many other health services.
Few patients reported interruptions in their supply of antiretroviral drugs (ARVs) even at the height of the crisis, although low supplies of certain first-line drugs did force doctors to temporarily change some patients' regimens.
|We just want to help each and every patient like we used to
About 153,000 patients are now receiving ARVs from public health facilities, according to the health ministry, just under half the number estimated to be in need of the drugs.
Madzorera predicts that Zimbabwe will achieve next year's universal access target for treatment, but evidence on the ground suggests his assessment may be overly optimistic.
Although ARVs are free and in good supply at most hospitals, drugs to treat opportunistic infections and the machinery to monitor HIV/AIDS patients are often unavailable
Getty Mutungwa, 43, had to sell her wardrobe last month to pay the rent on the room she shares with her five children and two grandchildren in Chitungwiza, a low-income suburb 20km outside Harare. Her health has been deteriorating since she tested HIV positive in 2004, but her local hospital requires results from several tests before they will initiate her on ARVs.
She has already paid US$5 for a CD4 count, but the hospital's equipment for conducting the other necessary tests is broken and she has been told to obtain them from the private sector at a cost of US$25. In the meantime, Mutungwa cannot even afford medication to treat a skin infection.
Years of government underfunding have forced public health facilities to raise their own budgets by charging user fees. These vary from one facility to the next with some hospitals charging HIV/AIDS patients up to US$10 for a consultation, and others only charging for CD4 counts and drugs not provided by donors.
Madzorera said the health department planned to phase out user fees for HIV/AIDS patients, children under five and maternity care, and to make fees for other services the same at all facilities. Other priorities include improving stocks of drugs and repairing broken machinery, plumbing and elevators.
In the meantime, patients are flocking to mission hospitals, where donors ensured that the supply of drugs and equipment continued even during last year's crisis.
"It's always very busy here; people come from outside our catchment area because we have all the facilities," said Judith Mataka, Sister-in-Charge at All Souls Mission Hospital, a bustling facility in rural Mutoko, two hours' drive northeast of Harare.
By comparison, the local public hospital in Mutoko is almost deserted. It lacks the equipment to conduct important tests for monitoring HIV-positive patients such as CD4 counts. "For those who can afford to get those [tests], they go to All Souls," said Kembo Chenjerai, a HIV/AIDS counsellor at the hospital.
Despite the lack of resources, Chenjerai and his colleagues at the hospital's opportunistic infections clinic are committed to their patients and prepared to give the new unity government a chance. But that commitment may evaporate if they do not start receiving proper salaries soon. "We're keeping on going because we should save people, but we're hungry," said Admore Majura, another counsellor.
Sister Margaret MacAllen, the head matron at Mashambanzou Care Trust, a non-governmental organisation that provides home-based and hospice care to families and individuals affected by HIV/AIDS in Harare, believes it is unrealistic to expect Zimbabwe's ARV programme to recover overnight from last year's crisis.
"I think we have to be patient and tolerant, and in the meantime focus on other things, like nutrition," she told IRIN/PlusNews. "The most important thing for us to know is that something is now happening every day ... Last year was probably the worst year in Zimbabwe's history, but I think we're recovering."
See also: ZIMBABWE: What price a CD4 test?