Harare, Zimbabwe — Those who remain must navigate a crumbling health care system -- and the moral, physical and mental costs that come with it.
At five months pregnant with her second child, Vimbai started bleeding. She suspected a miscarriage and rushed to a public clinic for help. The attending midwife didn't examine her, says Vimbai, who chose to use her middle name for fear of stigma. "The only thing they did was [give] me cotton wool."
To Vimbai's shock, the midwife wrote "attempted abortion" on her consultation card and referred her to the nearest public hospital about 20 kilometers away (nearly 12.5 miles). But Vimbai was in too much pain to make it all the way. "I thought I was going to die."
A friend recommended a nearby clinic operating illegally in someone's home. "I had a conviction that this was the only immediate option," she says.
Although the bed was uncomfortable, the home clinic was well equipped. There was a drip stand, boxes with cannulas, drugs and medical supplies stored in a tiny spare bedroom. The setup surprised Vimbai. There were other patients too. Their murmurs seeped through the walls. Somewhere, a child coughed. Vimbai also noticed something else. She knew the nurse who operated the backyard clinic. He worked as a midwife at the public clinic where she had been first treated after the bleeding incident. To Vimbai, this meant he was qualified. It reassured her a little.
They confirmed she was having a miscarriage, put her on intravenous therapy along with some injections and he cleaned her womb, she says. Overall, the experience was friendlier, and the midwife followed up afterward.
"The hideout clinics are saving a lot of people in the communities [where] we live," she adds.
Zimbabwe's health care system has been crumbling under the strain of years of economic and political instability, which started in the late 1990s. Health worker salaries have not been spared by inflation and currency challenges.
As a result, many professionals have migrated to seek better opportunities abroad. In 2019, the United Kingdom's National Health Service employed 4,049 Zimbabwean health care professionals, including doctors, nurses and clinical support staff, making Zimbabwe the second-largest African contributor to its workforce after Nigeria, according to a statement provided to Global Press Journal by Zimbabwe's Health Service Commission spokesperson, Tryfine Rachel Dzvukutu.
But not everyone leaves.
In late 2022, the country had 1,724 doctors and 17,245 nurses, Dzvukutu says, serving a population of over 15 million.
These doctors and nurses grapple with various challenges, among them poor salaries and high workloads. To navigate this, some take part-time jobs in other health centers while others operate illegal clinics such as the one Vimbai visited.
"Sometimes we resort to these hideout clinics not because we want to but because of the service we get at the public facilities," Vimbai says, her voice tinged with discontent.
A moral dilemma
Gladys, who has been a health worker for 20 years and asked to use only her first name for fear of retribution, says that sometimes she offers services to people in her community outside of work, especially those who might need minor assistance, such as dressing wounds.
"I do charge for rendering that service," she says. The cost ranges from 10 United States dollars or more per week, depending on what patients can afford. In comparison, the clinic where she works charges 1 dollar a day for minor services such as wound dressing. But Gladys says her fees are typically lower than the overall costs a patient would incur, including transportation. Other times, she says she doesn't charge if she sees that the person cannot afford to pay.
There has been an increase in these practices, even though it is illegal, says Simbarashe James Tafirenyika, president of the Zimbabwe Municipalities Nurses and Allied Workers Union. It's also unethical, since the workers offering these services don't have sterile equipment or other necessities, which is risky, he adds.
The Health Professions Act prohibits health institutions from operating without registration. Doing so is an offense liable to a fine, imprisonment up to two years or both.
Gladys doesn't think she is bending the rules or posing any additional risks to patients; if they visit the clinic, she is still the same person who will assist them, she says. However, she says those who operate more robust backyard clinics put people at high risk due to a lack of sterilized equipment. It is a criminal offense, she says, given the potentially fatal consequences, such as bleeding to death following an abortion.
Rueben Akili is a program officer with the Combined Harare Residents Association, an organization that advocates for the rights of residents. He confirms health care workers are operating illegal clinics in various high-density suburbs of Harare.
"It is an issue which we have noticed for the past five years due to the continuous deterioration of health service provision. They offer a range of services such as maternal health care provision, treating of sexually related diseases and to some extent general health care," he says. He sees it as a worrying trend as it puts people's lives in danger.
In a written response to Global Press Journal, Stanley Gama, the head of corporate communications for Harare City Council, says the council isn't aware of illegal clinics but will carry out investigations and enforce the law. He adds that health workers, like every citizen in Zimbabwe, haven't been spared by the challenges of the struggling economy.
Extra shifts
Gladys says her salary at the public clinic where she works is low. In March, the government paid her 6 million Zimbabwean dollars (about 195 US dollars). (At the time Global Press Journal interviewed sources for this article, the Zimbabwean dollar was still the standard currency in Zimbabwe. The country has since transitioned to a new currency, called Zimbabwean gold.) Gladys also receives an allowance of 112 US dollars. The total amount she receives varies each month depending on the exchange rate.
To make ends meet, Gladys takes extra shifts or works as a substitute nurse at private institutions. She prefers shifts at private institutions. The government clinic pays her 4 US dollars for a full day of work, from 7 a.m. to 7 p.m., and converts the payment to local currency at the prevailing exchange rate. The government also taxes this overtime pay. But the private health facilities pay her more money for fewer hours, at 20 US dollars for a day that ends at 4:30 p.m.
While extra work means more money, Gladys is always exhausted. She ends up working about 53 hours per week, well above the recommended 45 hours for health care workers.
"The body needs to rest. When you get home, all you want to do is sleep -- you can't do things that you would normally do like cooking, assisting your child with homework. We are overwhelmed," says the mother of two. Her social life suffers too.
She knows colleagues who have quit the public clinic to work in private institutions and others who have immigrated abroad. Around 2017 and 2018, the public clinic had 22 midwives, she says. Now, it has 14.
She considered leaving Zimbabwe for better opportunities abroad, but when she wanted to start the process, the government stopped issuing certificates of good standing. Without one, she would only be able to work as a care worker, which pays less than a professional nurse.
The solution for Gladys is for the government to employ more workers and offer better pay.
Although health care workers left behind like Gladys are finding solutions -- sometimes illegal -- to navigate the challenges of a crumbling health care system, these arrangements are unsustainable, says Tafirenyika, the union president. "What they are doing is bad and we do not recommend it at all, but they are looking for survival skills," he says. He blames the local councils, which employ public health workers. The solution, he says, is to ensure an adequate health care workforce and offer them good pay.
Gama says the Harare City Council has been recruiting more health workers. He did not provide any figures.
Enock Dongo, president of the Zimbabwe Nurses Association, agrees Zimbabwe's health workers are overwhelmed. The union is pushing the government to improve health workers' pay and welfare, he says.
"It's not only money that can solve the issues we are facing, but there are also many non-monetary benefits that they can provide like housing, land, farms, among others," he says.
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Side gigs
Although some health workers operate illegal clinics or take extra shifts to sustain their livelihood, others take up side gigs. Moyo, who prefers to use his clan totem for fear of retribution, is a nurse at a public hospital in Harare. He says his low pay gives him sleepless nights. It is so low that he couldn't add his fourth child to his medical insurance. "I was told that my income was too low to have another dependent added on my insurance. I can't even afford health care for my child," he says.
In February, his salary inclusive of allowances was 3.6 million Zimbabwean dollars (163 US dollars) plus a foreign currency component of 270 US dollars.
According to the latest Zimbabwe Statistical Agency report on poverty, the minimum monthly income needed in March for one person stood at 916,255.50 Zimbabwean dollars (41.54 US dollars). A family of six requires about 249 US dollars for food and non-food items to be above the poverty line.
Like Gladys, Moyo tried taking extra shifts at private clinics. He says lately they have been hard to come by. "Because of the economic situation in our country, the private health institutions are not getting as many clients as they used to," he says.
In 2023, he registered a consulting agency to assist students with their applications to private nursing schools in Zambia. "If I enroll 10 students, I get 20% commission. But because my company is fairly new, last year I managed to enroll three students and I was paid 200 [US dollars]," he says.
Despite the challenges, Moyo still wants to advance in his career. "I recently completed my bachelor's degree in nursing science, majoring in training, because I have a passion to teach. And if conditions of service improve, I intend to work in a nursing school locally," he says.
Although he could have relocated, he had someone close to him who was not well and he chose to stay. Home is best, he says. But those who leave are simply forced by circumstances.
