Harare, Zimbabwe — And outlining what it will take to get it back.
Wards bustling with highly motivated health care workers, readily available medication, decent salaries, a thriving teaching hospital network -- this defined Zimbabwe's health care system in the 1980s. Back then, it was considered a model of efficiency and effectiveness in Africa.
Today, however, the system is broken. Shortages of medical supplies, a crumbled infrastructure, and a mass exodus of health care workers have left the country unable to meet the needs of its people.
Among those left questioning the decline is Stella, who worked as a nurse in Zimbabwe in the 1980s and witnessed the system's heyday. She, like many others, wonders: What went wrong?
Stella, who chose to be identified only by her first name for fear of stigma, was 19 when she packed her bags to join St. David's Bonda Hospital, a nurse training institute in Nyanga, east of Harare near the border with Mozambique. This was in 1959, 21 years before the country gained independence from British colonial rule and four years after her mother died. In fact, it had been her mother's idea that she join nursing school.
"[She] told me that I would be able to take care of myself if I became a nurse," she says.
A model of efficiency
Soon after graduating, Stella moved to Zambia (then Northern Rhodesia) where she worked for two decades as a nurse at a copper mine hospital. Once Zimbabwe gained independence in 1980, she returned home and secured a job as a nurse in the capital of Harare.
Working in Zimbabwe immediately after independence was a stark difference for Stella compared to what she witnesses today. Health care workers had the resources to treat patients. "Ambulances were readily available," says Stella, who also worked as a midwife at a local clinic.
Felix Manyimbiri, a retired teacher, also remembers the good days. For him, it was the 1960s.
"I had pneumonia when I was around 10 years and at that time there were no clinics in our rural home. I was ferried in a Scotch cart to Ndanga District Hospital and got admitted for four days. I received good medical care; the doctor was on call 24/7," the 70-year-old says.
His wife, Moudy Manyimbiri, 62, remembers giving birth to their first child in 1980 at what was then Gweru General Hospital, a public hospital. "The nurses were there and provided a service I loved, all the necessities like cotton wool [and] Betadine [topical antiseptic], among others, were provided for," she says, a smile plastered on her face. The rewards for health care workers must have been good too, she says. "Nurses could afford to buy cars."
Zimbabwe's health care system even gained a reputation as a medical tourism destination within the region, says Dr. David Parirenyatwa, who served in the Ministry of Health and Child Care as a deputy minister (1998-2002) and minister (2002-2009, 2013-2018).
In fact, members of the Central African Federation, an economic and political alliance between Southern Rhodesia, Northern Rhodesia and Nyasaland (now Zimbabwe, Zambia and Malawi, respectively) considered Zimbabwe their health hub, Parirenyatwa says.
"The capital of the federation was Salisbury, now Harare, so things were happening here. The University of Rhodesia was the [training] university for the whole federation," he says, adding that citizens from the federation countries sought treatment at Andrew Fleming Hospital (now Parirenyatwa Group of Hospitals) and Harare Central Hospital (now Sally Mugabe Central Hospital).
"It was more like the medical tourism center," he says.
Mugabe's vision
This was a significant revival from the country's colonial past.
During Ian Smith's rule, who served as prime minister of what was then called Southern Rhodesia, from 1964 to 1979, health care favored the white minority population. For example, government funding to private services, which catered to whites, was five times more than public medical services in cities -- and 36 times more than public funding in rural areas.
Urban areas were staffed by 389 doctors, compared to just 11 doctors in the rural areas where 80% of the population lived, according to figures from Zimbabwean researcher Neddy Matshalaga.
But Robert Mugabe -- who became Zimbabwe's first post-independence prime minister -- would soon overhaul the system.
In 1975, Mugabe led a civil war against the white minority regime and in 1980, the country gained independence. Mugabe soon invested in health care, especially in rural areas, to address disparities. He allocated more resources to health care, built more facilities and increased immunization programs, to mention a few efforts.
In 1978, 134 World Health Organization member states -- including Zimbabwe -- had made a commitment at the Alma-Ata conference in Kazakhstan to protect and promote health for all people around the world.
Parirenyatwa says that in the early and late 1980s, several countries provided Zimbabwe with aid. "There was a lot of goodwill, health grew, and Zimbabwe was a center for all," he says. "We became top-notch."
What happened?
This didn't last long. Zimbabwe's health care system began to crumble.
The terms of the Lancaster House Agreement, signed in 1979 to abolish the white-dominated regime and pave the way for an independent Zimbabwe, were expiring. The most significant of the terms was white farmers' right to retain the land they occupied for 10 years, and in return the British would fund half the cost of a resettlement scheme for black farmers.
"Talk of taking the land back started, things started to go on a downward trajectory," Parirenyatwa says.
Sanctions followed. Funding to health care was reduced. Parirenyatwa's voice drops to a murmur as he recalls that time. "In 2000s, people [black majority] started taking their land back. 2002 sanctions were put in place. Things started going haywire."
Aid organizations stopped funding the health care system. For example, in 2002, the European Union withdrew its funding. Some groups packed up and left incomplete projects, Parirenyatwa says. The consequences of Zimbabwe's dependency on donors became evident.
In the 2000s, the economy in Zimbabwe also deteriorated, causing both a surge in skilled health worker emigration and a reduction in public spending, particularly in the social sector, including health care, according to recent research on Zimbabwe's health financing policy. As a result of reduced health spending, the government implemented both formal and informal user fees, decreasing the population's access to health care.
In 2006, as Zimbabwe's economic crisis intensified -- marked by inflation surpassing 1,000% -- Stella says she began to notice changes. Salaries were low. Staff morale plummeted. Medical staff no longer upheld ethics. "I felt hurt and sad knowing that people were being made to buy [supplies] that they should get for free," she says, frowning in disgust at the memories.
Things got even worse. Damaged beds remained unrepaired. A ward that previously accommodated 10 beds could only accommodate six, leading to premature discharge of new mothers to accommodate incoming patients.
"It was a disaster," she says as she folds her hands across her chest.
Some of her colleagues migrated to the United Kingdom and Ireland. However, some returned after an inclusive government between Zimbabwe's ruling ZANU-PF party and the opposition in 2009 adopted a multi-currency system as a measure to restore economic stability and curb hyperinflation. A period of social, economic and political stability followed.
The idea of migrating again was no longer an option for Stella because of her age. "If it wasn't for age, I would have left again," says Stella, who officially retired from nursing in 2012 due to age and ill health.
Health worker migration
Parirenyatwa says signs of the migration of health care workers began around 2002, as the country was going into a crisis due to land reforms. "Zimbabwean borders became literally porous for our health staff. South Africa and Botswana were the easiest destinations at the time. Up to now, a lot of our health people are in South Africa. Later on, it was not just South Africa, it was now other areas of the diaspora," he says.
He adds that around 2006, it became severe. "We began to lose our own specialists, especially in the nursing field -- intensive care nurses, theatre nurses," he says as he leans on his chair, tilting his head.
Although there was an increase in doctor positions in 2022, rising from 1,657 to 1,724, 147 doctors still terminated their services, according to data from the Health Service Commission. The nursing sector experienced a decline, with 1,454 nurses leaving their positions.
"Due to attrition, the number of public sector health workers has been reduced by at least 4,600 since 2019, despite increased recruitment," says Tryfine Rachel Dzvukutu, the deputy general manager of public relations for the commission.
In 2023, the World Health Organization listed Zimbabwe as one of the 55 countries that face the most pressing health workforce challenges related to universal health coverage.
"There are a lot of patriotic Zimbabweans who are leaving, but they are not staying partly because of our conditions of service. I don't know what we can do to satisfy that. We need to make sure those cadres who train have got a future that they can see, promote our own research and fund it -- it will keep our people here," Parirenyatwa says.
The solution?
The five most important elements of any health system, Parirenyatwa says, are human resources, drugs and medicines, infrastructure (buildings and hospital equipment), communication (including ambulances) and financing.
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When he worked in the ministry, Parirenyatwa says he advocated for the improvement of conditions of service for health workers and it led to the formation of the Health Services Board in 2005. "That alleviated pressures a bit, but because there were other things like infrastructure and equipment that were not in place, the frustrations continued to be there," he says.
To specifically address health worker migration, he says it's important for the government to address the causes first. "Without addressing these causes, we are going to keep having these problems. So it means massive funding in the health sector," he says.
He adds that the country should at least meet the 15% Abuja Declaration threshold for health budgets, as it would bring significant amounts of resources into the health sector. The Abuja Declaration is a commitment that was made in 2001 in Abuja, Nigeria, by African Union heads of state, who pledged to allocate at least 15% of their national budgets to their health sectors. To meet this commitment in 2024, Zimbabwe would need to allocate approximately 8.73 trillion Zimbabwean dollars (448 million United States dollars) from its 58.2 trillion-Zimbabwean dollar (2.98 billion-US dollar) national budget to the health sector. Instead, it has allocated 9.2% to the Ministry of Health and Child Care.
Meanwhile, the government is offering financial incentives to retain health workers, including regular adjustments to basic salaries to accommodate the rising cost of living and salary-based allowances, some of which are indexed in US dollars to hedge against inflation, says Dzvukutu, the Health Service Commission spokesperson.
Despite numerous challenges, not everything is broken.
Zimbabwe's health sector has shown progress in some areas, particularly in its response to the HIV/AIDS epidemic. The country was among the worst affected by the epidemic. It is now one of the few countries in the world that has achieved the 95-95-95 targets at a national level, according to a 2023 report by the Joint United Nations Programme on HIV/AIDS, known as UNAIDS. This means that 95% of people living with HIV are aware of their status, 95% of them are on medication, and 95% of those on medication have a suppressed viral load.
For Stella, the recovery of the country's health care system hinges on proper remuneration. "Most are leaving because they can no longer take care of their families, and general nurses are leaving a lot. I know of a number of people who have left," she says.
"People are leaving for greener pastures. If the pastures become greener here, we will be able to retain our workforce," she says.
