Paying for Health: Poverty and structural adjustment in Zimbabwe

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WA

Poverty andStructural Adjustment

in Zimbabwe

Jean Lennock

Oxfam Publications


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Oxfam (UK and Ireland) 1994A catalogue record for this book is available from the British Library

ISBN 085598 293 4

Published by Oxfam (UK and Ireland)274 Banbury Road, Oxford OX2 7DZ, UK(registered as a charity, no. 202918)Designed and typeset by Oxfam Design Departm ent OX 1042/PK/94Printed by Oxfam Print Uniton environment-friendly paperSet in 10 /12.5 point Pa latino with Franklin Gothic Book and Demi

This book converted to digital file in 2010


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ContentsForeword 4Acknowledgements 4Summary 5A beacon of progress? 6Food security and nutrition 9A health system in decline 14Counting the costs 18The case against user-fees 20The Social Developm ent Fund 23Markets and access 28To improve health, invest in education 32Conclusion 35Sources 37Further reading 39


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ForewordThis study examines changes in the financing of health services inZimbabwe, and their impact on low-income groups. It is based ona series of interviews conducted over a two-week period inAugust 1993. Sixteen women, living mainly in rural areas inManicaland, Masvingo, South Matebeleland, North Matebele-land, and North and East Mashonaland, were interviewed. Theinterviews were facilitated by the staff of Oxfam (UK andIreland), in liaison with Oxfam project partners in Zimbabwe.Only one of the wom en interviewed had any direct involvem entin an Oxfam-supported project.

AcknowledgementsMany people su pported me in the writing of this report. Specialthanks are due to Dr Anne Renfrew of St Pau l's Mission H ospital,for inform ation on the effects of user-fees on the lives of people inlocal communities. Drs Peter and Ginny Iliff supplied statisticson attendance at ante-natal clinics and trends in maternal andperinatal m ortality at Harare Central Hospital. I received invalu-able advice from the late Dr Peter Fear and nursing staff at BingaDistrict Hospital and from Stefan German, Administrator atTshelanyemba Hospital. Ruvimbo Mujeni and staff in Oxfam'sHarare office arranged the interviews which form the basis ofmuch of this report, and Anni Long in the Policy Department atOxfam House provided administrative support. Above all, Ithank the many women in villages across Zimbabwe who tookthe time to explain the effects of user-fees on their lives. Sadly,their voices are seldom heard by policy makers.Exchange ratesAt the time of writing (August 1993) 1 = Z$10. At the tim e of pub-lication (June 1994), 1 = Z$12.


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SummaryPolicy statements by the World Bank and the InternationalMonetary Fund (IMF) increasingly stress the importance ofintegrating poverty-reduction strategies into structural adjust-ment programmes. These statements attach particular import-ance to protecting the provision of basic health services to poorcommunities through public investment in social-welfarefacilities. However, the experience of Zimbabwe, which is oftenpresented as a model of poverty-oriented adjustment, suggests adivergence between principles and practice. Expenditure percapita on health and education has fallen steeply, eroding thequality of provision in both areas. Moreover, the introduction ofuser-fees initially on the recommendation of the World Bank as a mechanism for meeting targets to reduce the fiscal deficithas excluded poor people from the health system, with disastro usconsequences for human welfare. Alternative ways of meetingrealistic budget targets, such as increased taxation of higher-income groups, have been rejected in favour of what am ounts toa regressive system of taxation on the poor. The result isincreasing inequities within the health system, compounded bythe inefficiency and high costs of adminis tering the user-fees. Anexemption system ostensibly designed to protect the poor hasfailed to do so effectively, because it suffers from inadequateresources, and from poor design and implem entation.Contrary to World Bank claims, social exp end iture in Zimbabw ehas not succeeded in shielding the poor from adjustmen t. Indeed,the burden of adjustment has been disproportionately borne bypoor peop le, both in terms of falling real incomes and in terms ofreduced access to health and education services. This suggeststhat more effective mechanisms for protecting the poor should bebuilt into adjustment program mes.


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A beacon of progress?Zimbabwe made impressive progress in health-care in the yearsfollowing independence in 1980. Life expectancy increased to 60years, imm unisation program m es w ere extended to cover over80 per cent of the popu lation, and by 1989 infant mortality ra teshad fallen to 46 per 1,000 live births. These achievementsprompted a recent UNICEF report to describe Zimbabwe as 'abeacon for progress towards child survival and development insub-Saharan Africa'. By contrast with the rest of sub-SaharanAfrica, Zimbabwe's health-status indicators com pare favourablywith those of countries in other developing regions, includingthose with higher income levels.Today, however, the achievements of Zimbabwe's post-independence health policies are under threat. The resourcesavailable for investment in the social sector have been reduced,and the welfare of poor people unde rm ined , by a combination offactors: slow growth during the 1980s, a crippling economicdo w ntur n caused by drou ght in 1992, and the budge taryconstraints imposed by a structural adjustment programme(SAP) administered under the auspices of the World Bank andthe International M onetary Fund (IMF).

User-fees penalise the poorThe government of Zimbabwe has responded to the constraintson its budge t by raising the levels of user-fees for health care. TheFramework for Economic Reform (1991-95), drawn up in closeco-operation with the World Bank and the IMF, incorporatedambitious targets for increasing revenues from user-fees from$Z15 million in 1989/90 to $Z60 million by the end of 1995. Thesetargets, and the policy framew ork for health reform set ou t in theFramework for Economic Reform, were informed by recom-mendations made in two influential reports by the World Bankon the financing of Zimbabwe's health system. Both reports(World Bank 1990,1992) argued as follows:


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A beacon of progress? that the level of user-fees w as set too low; that efforts to collect revenu e were inad equate; that the system of exemptions for low-income groups was

undu ly complex.W ithout any empirical evidence, the Bank also argued that p oorenforcement of the user-fee system was costing between 2 percent and 4 per cent of the Ministry of Health budge t. Although theWorld Bank has not incorporated targets for cost-recovery intothe conditions attached to its adjustment loans, it has suggestedthat the share of the health bud get generated by user-fees couldbe increased from 3 per cent to as much as 33 per cent. There islittle doubt that such optimistic assessments have had animportant influence on the governm ent of Zimbabwe.Developments in Zimbabwe reflect the general trend towardsmarket-orientated prescriptions for the provision of healthservices. However, contrary to the claims made for theseprescriptions, the evidence from Zimbabw e suggests that hea lthplanners have been unable to combine market principles in thepricing of health services with the principles of equity andefficiency. This study confirms the finding of a grow ing body ofresearch which indicates that user-fees have the effect of pricing health services beyondthe means of those most in need; that exem ption systems do not effectively protec t the access of

poor people to health services; and that, for poor people, user-fees set at even modest levelsund erm ine access to basic health care.

Private health-care is not the answerWhat makes the failure of the reforms so dam aging in Z imbabweis that public health is deteriora ting in the context of rising foodprices, increased unem ploym ent, and especially for wom en longer working hours resulting from the economic crisis. As inother countries in sub-Saharan Africa, private health care,regarded by proponents of market-orientated reforms as a


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Paying for Health

poten tial substitute for state provision, does not prov ide a viablealternative to public health systems. This is because the poor haveminimal cash incomes, and few can afford social insurance.W idespread redundan cies in the formal em ploym ent sector willfurther limit any prospect of the priva te sector substituting for thestate.Exemption systems don't workThe current s tudy also calls into question the claims of the WorldBank and the government of Zimbabwe that the country'sadjustment programme incorporates mechanisms for protectingthe health of the poor d uring adjustment. Despite the mountingbody of evidence showing a clear correlation between user-feesand worsening health indicators, the government of Zimbabweincreased these fees and imposed more stringent conditions fortheir collection in Janua ry 1994. The W orld Bank has so far failedto recommend the phasing out of user-fees, despite evidencefrom doctors, nurses, non-government organisations, and usersof health services that the exemption system has failed dismally.Real spending on health is in declineEqually disconcerting has been the decline in real spending percapita on health. It is true that this decline is partly attributable toeconomic constraints. None the less, the reduction in socialexpenditure is inconsistent with the World Bank's claim to havenegotiated a com mitment from the governm ent of Zimbabw e tomaintain health spending in real terms during the adjustmentprogramme.


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is spent on staples; meat and milk are often cut out of the dietaltogether. Many families are cutting down on the number ofmeals eaten during the day, with inevitable consequences fortheir health and nutritional status.Rising food prices in the face of falling wages have had especiallyserious consequences for low-income urban households. Butfood insecurity is also endemic in rural areas, despiteZimbabwe's post-independence achievement of national self-sufficiency in basic foods. Even before the dro ught , insecure foodsupplies affected an estimated 40 per cent of rural households.These households are dependent on income raised from sellingsurplus crops to buy essentials like sugar, salt, soap , cooking oil,and fuel. In communal land and resettlement areas, almost allhouseholds plant maize, and three-quarters plant vegetables. Yetover 40 per cent of such households produce less than theyconsume each year, which leaves them extremely vulnerable torising food prices.Resources depleted by droughtAgainst this background, the 1992 droug ht dealt a crippling blowto household food security, with up to 100 per cent of crops beingdestroyed in some areas. The drought also depleted capitalstocks. Most goats and cattle died , and people used up their smallsavings to purchase essentials. This has left ru ral people with fewreserves on which to draw . In March 1993 over 70 per cent of ru ralhouseholds were still depe ndent on drought-relief assistance.The story of Mrs Mugwira, who lives in a village in a semi-aridarea two hours from Masvingo, is not untypical. She has sevenchildren and her husban d w orks in the city, sending money homewhen he can. She recalls how hard it was dur ing the drou ght:Before the 1992 drought w e had 26 ca ttle, but all of them died. We weregetting drought relief, but there was not enough for all of thefamihj. Wehave grown some food this year, but w e cannot sell any, in case the rainsfail again.

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Food security and nutritionFor people like Mrs Mugwira the 1992 drought, which brieflygrabbed the headlines in the North , was not an isolated event. Insemi-arid areas, near-drought conditions prevail in most years,making agriculture and survival a hazardous affair.

Malnutrition is on the increaseFood-security problem s are reflected above all in a high incidenceof malnutrition. One recent survey (UNICEF/GoZ 1993a)established a 5.7 per cent incidence of moderate and severe mal-nutrition in urban high-density sites, a 9.5 per cent incidence oncom munal land sites, and a 12.2 per cent incidence on large-scalecommercial farms. Those working as labourers on commercialfarms a re particularly vulnerable, because of their extremely lowincomes and insecurity of employment. In commercial areasaround the area of Musami, many labourers were earning justZ$140 per month (14) when we conducted our interview s.In the semi-arid areas of Binga District, nutritional status is evenmore w orrying. At the very beginning of the drought, a study bythe Save the Children Fund (SCF 1993) discovered a 15 per centincidence of stun ting by age, a sign of chronic m alnutrition. Lowweight-for-age w as found in 32 per cent of under-fives exam ined,and one third of mo thers had low m id-uppe r-arm circumference,an indication of low fat reserves.Sophia Mutare, one of the women interview ed for this survey, isa married woman living in Nsenga village in Binga district. Herexperience is typical of the problem of erratic food supplieswhich many househo lds face. She has five children. She and herhusband are farmers, but they do not produce a surplu s, and theyneed to buy mealie meal:/ don't have enough food for the children. We do not have money to buyany more; we have to buy mealie meal and salt, but we cannot affordsugar. The children have started to lose weight, and 1 know they willsoon begin to get sick.

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The malnourishment suffered by her children makes them lessresistant to infections and much much more vulnerable todisease. A malnourished child will have four times the number ofdiarrhoea attacks as a well-nourished child. In Binga district 60per cent of malnourished children w ere ill, compared with 40 percent of those who showed no evidence of malnutrition. Illnesswas found to be much more commonly associated with acutemalnutrition. As Mrs Mugwira observed:In the village, diseases are increasing; there is more malaria, morediarrhoea, and more kivashiorkor [a form of protein malnutrition]. Evenamong adults you can see they are losing weight, because they don't eatnutritious seeds, beans, and nuts.The lasting consequences of malnutrition are severe, taking up totwo generations for girls to 'wash out' the effects of severemalnutrition. It weakens their reproductive systems, with theresult that their children may be more vulnerable to ill health,even if they are well fed.Nutritional status correlates strongly with family income.Inadequate incomes from employment or surplus foodproduction are a major cause of malnutrition in areas such asBinga, where 56 per cent of men had no form of cash income.When women lack a cash income, the problem is even worse. InBinga District, all forms of malnutrition fell when the householdhad an income, but the fall was much more dramatic whenmothers had a cash income. This underlines the case forenhancing women's employment and income-generatingcapacity. The incidence of acute malnutrition when neitherparent had an income w as 49 per cent, dropping to 33 per centwith paternal income, and to 14 per cent with maternal income.However, 82 per cent of women had no form of cash income. As aresult, female-headed households are more vulnerable to foodshortage than those with an adult m ale mem ber. Seventy-two percent of female-headed households reported a food shortage,compared with 63 per cent of those with an adu lt male mem ber(Save the C hild ren, 1993).

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Food security and nutritionBrewing beer for sale is one of the m ost common sources of cashfor rural women, although the revenue they raise is ofteninsufficient. Mary Muleya, a single parent w ith three children, isa farmer in Binga District. She grow s sorg hum , millet, and som evegetables, but cannot grow enough for her family, because shelacks capital and has no plough or draught animal.My only way of getting money is through selling beer, but 1 can only buyessentials, those things that stop you from dying.As pove rty rises and living standards deteriorate, the effects ofdeclining expenditure on health are comp ounding the decline inhealth standards for most of the population. As a nursing sister inBinga observed:1 have seen things get harder, watched breadwinners lose jobs, takechildren out of school, lose their home, and become sick. Diseases andsuffering are increasing, things are getting worse.

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A health system in declineThe World Bank claims that it negotiated a pledge from theZimbabwe government to maintain the health budget d uring theadjustment programme. However, allocations for health fellfrom 4.8 per cent of the budget in 1991/92 to 4.5 per cent in1992/93. As a share of national income, spend ing on health hasnow fallen to 2.7 per cent the lowest since independence . Moredisconcertingly, health spending per person has fallen from $Z52in 1990/91 to Z$40 this year. Under pressure from the WorldBank, the Zimbabwean government has increased expendituresince 1992. How ever, a nominal increase in the 1992/93 budget ofabout Z$70 million am oun ted to a decline in real terms of around20 per cent. The 1993/94 budget announced a Z$150 millionincrease in the budget allocation for health an d child welfare, a 20per cent rise at a time when general inflation was running at 28per cent, and considerably more in the health sector.Low investment in essential medicines ...These cuts have significant implications for the funding of theGovernment Medical Stores, which supply 80 per cent of alldrugs to government health institutions. The real value of thedrug fund declined by 13 per cent between 1991 and 1992,creating shortages of essential drugs in many clinics andhospitals. Improvements since then have occurred principallythrough an increase in support from international don ors.Retrenchment in spending on drugs has severely limited thesupplies of medication at health outlets. There is considerableevidence that patients are increasingly by-passing primary andeven district-level health facilities because essential drugs areunavailable there. This was apparent at the St Paul's MissionHospital, just an hour's journey from Harare. In August 1993,when ou r interviews were conducted, the pharmacy had ru n out14


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A health system in declineof Diazepam and Lignocaine (both essential for minor surgery),Gentamycin (an antibiotic), M ethyldopa (an anti-hypertensive),and several other basic drugs. The medical staff acknowledgedthat they were unable to treat patients effectively, which maymean retu rn visits for patients, costing them time away from theirwork and money in bus fare. There is no local pharmacy wherepatients can buy the drugs, even if they had the resources to do so.... and vaccination programmes ...Staff at St Paul's Mission Hospital are also responsible foradministering the Expanded Program me on Imm unisation (EPI).This programme aims to vaccinate children against majorinfectious diseases and is an essential aspect of the Zimbabweangovernment's primary health care programme. A major part ofthe EPI is administered from mobile clinics, by staff from healthcentres and hospitals. Staff from the hosp ital maintained monthlyvisits to 42 outreach points until mid-1991, when they wereinstructed to cut the outreach w ork, because funds were no longeravailable to cover transport costs. Twenty-one centres wereclosed, leaving mothers in many areas to travel long distances forvaccinations. A rapid fall in the numbers attending outreachpoin ts was observed in the second half of 1991.... and medical equipmentThe supply of medical equipment has also deteriorated inresponse to expenditure cuts. In Au gust 1993 Harare CentralHospital Maternity Unit (HMU) had no ultrasound scan or acardiotocograph in working order. These two pieces ofequipment are essential for the monitoring of foetal well-beingthroughout pregnancy and during labour. Since many womenare referred to HMU because they show signs of complications,the failure to maintain this basic diagnostic equipment under-mines the ability of staff to prevent potentially fatal problems.This is reflected in the fact that institutional failures wererecorded in 69 per cent of the maternal cases which resulted inmortality. These failures ranged from poor diagnosis to lack of

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Paying for Healthintensive-care beds, shortage of blood for transfusion to lack ofantibiotics.A two-tier health systemIn effect, the financial constraints operating on the public-healthsystem are accelerating the development of a two-tier healthstructure, w ith those wh o are unable to pay bearing the bru nt ofthe cost. Women with sufficient money can purchase obstetriccare with the latest investigative techniques and monitoringequipment at 'The Avenues', Harare's private hospital situatedclose to the government maternity unit. This is ironic, becausewomen with the greatest economic resources are least likely torequire detailed investigation, while women from low-incomefamilies, who begin their reproductive life at an early age, haveseveral closely spaced p regnancies, and suffer from poor generalnutrition and health, are most likely to suffer from obstetriccomplications.Lower sta ffing levels ...Staffing levels provide another indicator of the impact offinancial cuts. Numbers of personnel have been frozen since1992, even where the size of the hospital has increased. BingaDistrict Hospital, for example, had the same staffing levels in1993 as in 1989. Then average bed-occupancy w as 70 per day; thecurrent occupancy is at least 140 per day, rising to 250 atparticularly critical times. Several hospital administrators inter-viewed for this study stated that changes in recruitment policywere further eroding staffing levels. Under existing rules,hospitals are not allowed to replace staff who leave, withoutseeking perm ission from the provincial medical director. Even ifperm ission to appoint is granted , the job must be offered to a'retrenched' person, which creates long bureaucratic delays.

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A health system in decline

... and lower staff moraleAlmost all of the nursing staff interviewed spoke of the way thatstaff morale had been undermined by increasing workloads andfalling pay. Over the past three years the salaries of healthprofessionals have fallen far behind the rate of inflation. Anursing Sister comm ented:I cannot afford to make ends meet on a daily basis. Prices are soexpensive, I cannot even think of boarding a bus to buy food, because oftransport costs.Moreover, despite the worsening staff-patient ratios, anincreasing num ber of the nurses wh o qualify each year are unab leto find permanent employment.Doctors, too, are increasingly demoralised. As they struggle tocope with an ever-more demanding workload, with fewer andmore junior staff, inadeq uate technological back -up, and greaterbureaucracy, their commitment is pushed to its limits. Many areunderstandably attracted to the priva te sector, or to countries thatoffer considerably higher rates of pay. An estimated 70 pe rce nto fphysicians and 60 per cent of nurses are privately employed,either in Zimbabwe or in neighbouring countries. This is one ofthe hidden costs of retrenchment and one which raises seriousquestions abou t the case for financial stringency. It is surely not acost-effective policy to train staff, at considerable expense to taxpayers, only to have them work outside the government healthservice.

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Counting the costsThe effects of financial cuts in health spe nd ing and user-fees arebeginning to show in Zimbabwe's health-status indicators,which are deterio rating for the first time since indepen dence. Lifeexpectancy, which w as only 45 in 1979, had risen to 64 in 1989. By1991 it had fallen to 60 years (UK: 75 years). The infant mortalityrate (IMR) in 1970 was 98 per 1,000 live births. In 1989 M R hadfallen to 46, bu t had risen to 48 in 1991 (UK: 9). IMR in Hararedistrict increased from 23 in 1989 to 43 in 1992.Maternal mortality is increasingMaternal deaths nationally declined until 1989, but have recentlyincreased dramatically by 240 per cent between 1989 and 1991.Maternal mortality rates at Harare's main obstetric centresdoubled between 1991 and 1992 among the resident population ,and rose by 40 per cent among the non-resident populationreferred to the hosp ital, a higher-risk g rou p. While it is difficult toprove a causal relationship between these trends and theintroduc tion of user-fees, the prima facie case is a compelling one.For example, statistics from Harare Central Hospital show anincrease from 8.8 per cent in 1991 to 13.6 per cent in 1993 in thenumber of babies born to mothers who had not registered forante-natal care. The perinatal mortality rate for unregisteredmothers is 251 per 100,000 live births, compared with 53.8 for'booked' patients.The threa t of HIV/AIDSHIV/AIDS is likely to have a significant effect on deterioratinghealth indicators, since Zimbabwe has an estimated HIVprevalence of 25 per cent among adults. However, it does notsufficiently account for the worsening trends discussed above.Over half of the women who died in childbirth at Harare's18


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Counting the costsGreater Maternity Unit showed no evidence of HIV-relatedsymptoms. The incidence of infections after childbirth, anindicator of HIV infection, w ould be expected to rise if HIV werethe major associated cause but levels of infection haveremained constant.Fewer patients are attending clinicsUNICEF's sentinel site surveys (UNICEF/GoZ 1992, 1993a,1993b) provide further evidence of a connection betweendeclining access to health services and the introduction of user-fees. The second of these surveys, which covered a ttend ance at 36hospitals and health units between August 1991 and 1992,recorded a 22 per cent decline in patient registration in com munalareas and 64 per cent in large-scale commercial farming areas. Ofthose parents who did not take children with diarrhoea to a healthcentre, 20 per cent said it was too costly. By the time of the thirdsurvey (October 1992 to March 1993), this figure had fallen to 7per cent, following the government's decision to allow the freeuse of health facilities for the trea tment of d iarrhoea .One factor behind the worsening indicators is the cut-back inoutreach programmes. Distance is an increasingly significantbarrier to health services for many vulnerable com munities w hoare unable to attend clinics without transport. Precisely thisproblem had confronted Mrs Chibidi, who lives in the village ofMukorobi Munhu Ndagwa in Mashonaland with her husbandand one of her children . She told us:/ have been ill with a very bad cough and w anted to go to the clinic. Bu tit is too far: it takes more than tiuo hours' walk if you are feeling w ell, andif you are sick it will takelonger. The distance is a problem forme. Nursesused to com e to the village, but these days we don't see them; they musthave better things to do.

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The case against user-fees

User-fees have always been part of the Zimbabwean govern-m ent's health policy. How ever, in June 1991, and again inJanuary 1994, fees were increased and more rigorous enforce-ment criteria introduced. The government and the World Bankhave justified user-fees by three interlocking a rgum ents.Arguments in favour of user-fees First, increased government revenue was presented as one ofthe keys to meeting targets for reducing the government'sfiscal deficit from 10 per cent of GDP in 1990/91 to 5 per cent by

1995. Since increased taxation on higher-income groups wasruled out, user-fees in health and education assumed pivotalimportance as a highly regressive form of taxation. Second, the government claimed that a fee structure wasneeded to channel patients to the most appropriate point ofentry to the health-care service, through a system of graduatedpay m ents, increasing from the prim ary level to the provinciallevel. The aim of these payments, according to thegovernment, was to deter patients from by-passing primary

clinics and going directly to hospitals, and thereby under-mining the referral system. Third, both the World Bank and the governm ent of Zim babweclaimed that the generation of resources within the healthsystem would improve efficiency and equity.The counter-argumentsAll of these argum ents were deeply flawed. Firstly, while the fiscal deficit may have been unsustainable,the burden of reducing it need not have been placed on the

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The case against user-feesshoulders of the poor. There were other options, such asincreased taxation on higher-income groups through a landtax and corporate taxes, allied to reduced subsidies forparastatals and lower military expenditure. These wererejected for political reasons, notably the refusal of thegovernment to confront vested interests.

Secondly, the breakd ow n of the referral system w as due less tomarket considerations and more to the collapse of primaryhealth-care provision, which gave pa tients an incentive to seekhigher-level facilities. Finally, while revenues from user-fees could provide resourcesfor the health sector, they do not play this role in Zimbabwe.Under Ministry of Finance rules, the revenue generated byuser-fees, as with any o ther form of taxation, is autom aticallytransferred to the general budget account. In other words,user-fees in Zimbabwe are an instrument of fiscal policy,rather than a mechanism for improving the health system.The dangers of self-medicationIn defence of user-fees, the World Bank has argued that they are ameans of mobilising people's willingness and ability to pay forhealth care. The fact that people make out-of-pocket payments forhealth care is cited as evidence of this willingness and ability. Butthe women we interviewed made few out-of-pocket payments,and these were far below the cost of health-centre fees, transport,and medication. Sophia Mutare from Nsenga told us:/ buy tablets from the shop, because I don't have the money to go to thehospital; the shop keeper will tell me w hat tablets I need, but I can onlybuy a few, because of the money.Wom en buy tablets at the village sho p often because they cannotafford to attend the clinic. In our interview s they expressed concernthat they were not getting the correct medication. Doctors told usthat self-medication was leading to many problems from drugresistance, particularly in malarial areas.

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Paying for Hea lth

Out-of-pocket payments for traditional healers are often treatedby the W orld Bank as further evidence of ability to pay . But noneof the women we spoke to could afford to consult a traditionalhealer. In Zim babw e traditional healers provide a service seen bymost users as complemen tary to, not a substitute for, orthodoxmedicine. In this context it is simplistic to argu e that, if people canpay for traditional m edicine, they can pay to use health centres.User-fees as a proportion of household incomeAnother argument advanced by advocates of user-fees is thateven the poor can afford health fees since, averaged out over thecourse of a year, they represent a small prop ortion of householdincome. This may be true for some households, but it ignores thereality in which poor people operate. For example, with limiteddisposab le incom e, the costs of ante-natal care might represent asmall proportion of annual income, bu t a substantial proportionof the cash available for essential food and non-food purchases.Moreover, the amou nt of cash available varies throughout theyear in rural areas, notably between the pre- and post-harvestperiods. Most poor rural families experience chronic cashshortages in the immediate pre-harvest period, during whichthey often work for payment-in-kind.Opportunity costsBy focusing on average incom es, advocates of user-fees also ignorethe opportunity costs involved in seeking health care. These areconsiderab le, even in the absence of fees, since time spent awayfrom land or work often poses a threat to the livelihoods of thepoor. Bekezela Ndebele lives in Sigangatsha with her daughter,while her husband works in South Africa. She told us:There is nothing I can do togeneratean income. I grow some food, but itis not enough. The clinic is two hours' walk away, but sometimes Iborrow a bicycle and then it only takes one and a half hours. 1 have to usethe bike, as 1 do not have the bus fare and I cannot borrow it.

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The Social Development FundThe Zimbabwean Social Development Fund is the mechanismdesigned to protect the poor from the economic impact ofadjustment, including the effects of user-charges for health care.The Fund has a social-welfare component, designed to offersupport in areas of health, education, and food supplies . For thosewith a household monthly income of less than Z$400 per month,exemptions from health and education fees can be granted. Forthose whose income is less than Z$200 per month, food moneycan be granted at a rate of Z $4 per person per m onth. Exemption system s: underfunded ...However, it is inconceivable that the fund, w ith a revenue base ofonly Z$430 million, was genuinely intended to meet the needs ofall those eligible for support. This has been confirmed byexperience. Fewer than 10 per cent of households eligible foreducation support have received funds, and the first health-exemption paym ents were not m ade until March 1993. Moreover,the design and implem entation of the system for exem ption fromhealth fees has been arb itrary and inefficient. One problem is thatthe level for exemptions is set too low. Household income belowZ$400 per month entitles families to exem ptions from health fees.How ever, the national poverty datum line is Z$593 per month fora family of six. Unless a new formula is devised to considerincome per head of household, the fixed exemption level willcontinue to discriminate against those with larger families already a very vulnerable group.Many households whose income is over Z $400 are still not able toafford the fees. Take the case of Mr Madonga , w ho w orks in afactory and earns Z$450 per m onth . Ou t of this he has to pay forfood, rent, electricity, transpor t, water, and education . In 1992 afamily living in a low-income urban settlement would spend an

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Paying for Hea lthaverage of Z$727 per month on these items. To generate extraincome, Mr M adonga 's wife sells beer. Because of his salary he isnot exempt from charges for health care. Attending out-patientswill cost him Z$10 per adu lt; each in-patient day will cost Z$25.The costs of prov idin g for his family of six already ou tweigh M rMadonga's income, and it is impossible for him to pay suchhealth charges.... poorly administered ...Vulnerable groups are made even worse off by theadministration of the user-fee system. A World Bank study ofhealth financing in Zimbabwe (World Bank, 1990) argued thatmany people not eligible for exemptions w ere receiving them onthe basis of a verbal statement to staff at health facilities. Thosehospitals that demanded proof of low income from the patienthad correspondingly higher levels of cost-recovery. The reportrecom mended that the bu rde n of proof of income be placed up onthe patient, with letters from social service agencies required toconfirm eligibility. The authors suggest this 'should not createexcessive difficulties'. However, despite the reassuring tone ofthe Bank's report, the resulting confusion and randomimplem entation of this policy has served to exclude those most inneed.Under current directives, all patients applying for an exemptionfrom health fees are required to demonstrate eligibility, in the formof either wage slips or a letter from the local Social Welfare Officer.Since an estimated 90 per cent of the population should be exemptfrom charges, and only a small number are formally employed,these criteria are of dubious relevance. In practice, most peopleneed assessm ent by a Social Welfare Officer, but it is often difficultto obtain. In some areas the bus fare to the nearest adm inistrativecentre costs more than the fee for registering at a health centre orhospital. Moreover, for women in particular there is a highopportunity cost, since time normally spent in producing food,earning money, and looking after children is spent instead onvisiting and queuing for an exemption certificate.24


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The Social Development FundSarah Moosha, a farmer from Nyamarirwe Kubatana, Manica-land, typified the attitude of many of the wom en we interv iewed.Her husband is unemployed and no longer lives with her. She hasto support herself and her five children. Her only income comesfrom looking after maize fields for a local co-operative. Sheexplained:We hear about these letters, but in reality it is not possible to get them. Iwould have to get the bus to the office, which would cost me Z$10 eachvisit, and I need that money for cooking oil and soap.It wo uld take Sarah at least two journeys to get the letter, possiblymore. The Social Welfare department lacks the capacity tomobilise its resources effectively. The task of screening forexemptions was added to its already high workload, at a timewhen the department's budget was cut by 25.6 per cent in realterms. As a result, staff have been totally unable to meet the needsof people applying for assistance.Patients living in the catchmen t area of St Pau l's Mission H ospitalface prob lems similar to those of Sarah M oosha. The nearest socialwelfare office is 45km away, and each journey costs Z$8. Mostfamilies might be able to afford this immediately after sellingtheir harvest, but during the 'hungry period', when thehousehold's food reserves are depleted, this cost would bebeyond the reach of many of the poor.... and arbitraryThe atti tud es of staff to claim ants can have a significant effect onaccess to welfare payments. Roda Ncube is a married womanwith three children. She lives in Sigangatsha, SouthMatebeleland, while her husband works in South Africa. Sheearns a little money from selling beer, and qualifies for anexemption./ can take a letter to the clinic from my village development w orker. Theworker will give m e the letter when I need it, after asking questions aboutmy husband and my work. It doesn't cost anything.

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But Sophia M utare's experience of the system w as less positive:/ visited the hospital and said that I had no money to pay, so they askedquestions about my husband, looked at my clothes, and then asked otherpeople what they knew about my family. It's bad that they decide likethis, but you cannot do anything.In the absence of app rop riate staff training and supervision, it isnot surprising that decision-making has become so arbitrary andsubjective. But such subjectivity is problematic. Many women,like Sophia, reported feeling degraded by the questions asked,and were given the impression that they would receive aninferior service since they could not pay.Even with letters to certify low incom e, in some areas people a reexpected to pay, albeit at a reduced rate. However, for some of thewomen we interviewed the reductions were not enough toensure basic health care. For example, Elizabeth Zhizha fromMukorobi Munhu Ndagwa has six children. The last two wereborn at home because of the charges.I can take a letter from the Councillor which means I have to pay Z$10for maternity care. Without the letter I would have to pay more. There isno free maternity care here and Z$10 is too much for me.There is similar evidence of bureaucratic flaws in theadministration of the Social Development Fund with regard tofood money and school fees. The fund would have beenimm ediately ba nkrup ted if all those eligible for food money hadapplied, but by August 1993 only 6 per cent had applied. ByAugust 1993 no funds had made available to schools for thoseeligible for exemption from school fees, with the result that manychildren have been refused admission (UNICEF/GoZ, 1993b).Action to improve the exemption systemAs a result of international and domestic pressu re, the exemptionsystem in urban areas w as extended in May 1993. Residents inhigh-density areas will not need assessment by Social Welfare,because targeting will be done through health establishments.26


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The Social Development FundThose in low-density areas will still go to Social Welfare. Itremains to be seen whether or not these changes will improve theadministration of the exemption system. But, looking to thefuture, it is clear that the system will need to be properlyresourced, if it is to protect the poor more effectively. Increasednum bers of staff in rural offices are requ ired, as are good trainingand a large-scale education campaign to inform people of theirrights. Unfortunately none of this seems likely in the currentpolitical and financial climate.

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In this context of rising user-fees and a badly designed and poorlyimplemented exemption system, it is not surprising that poorgroups are being excluded from the health service. Figures fromhealth institutions show reductions in attendances across thecoun try. Between August 1991 and 1992, a study of 36 healthunits revealed an 18 per cent decline in out-patient attendancesand a 27 per cent decline in in-patient loads. This was despitesharp increases in malnutrition caused by the drought. At StPaul's Mission Hospital near Harare, maternity in-patient daysfell by 33 per cent following the increase in user-fees in 1991.User-fees deter maternity admissionsStatistics from Harare Central Hospital Maternity Unit show a 21per cent increase in the numbers of babies 'born before arrival'and later requiring admission due to problems. This increaseoccurred in the six m onths following the stricter enforcement ofcharges in June 1991. Among these babies, mortality rose by 156per cent in the same period. Surveys in January 1993 confirmedthat one of the major reasons given for giving birth at hom e wasthe cost of delivery at health facilities.Health charges weighed heavily in the decision of Sarah M ooshafrom M anicaland to deliver four of her children at hom e:I gave birth to two of my children alone and family helped with theothers. It is very hard giving birth on your own; you are so tired, but youhave to get up, to make sure that the baby can breathe. 1 wanted to go tothe hospital, but I w ould have had to pay Z$10 and take things for thebaby which I can't afford.An increasing num ber of wom en w ho do deliver in hospital arereques ting early discharge after delivery, to reduce costs, often atthe expense of their welfare. In HMU a growing number of28


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Markets and accesswomen pa tients are leaving early because they cannot afford thedaily charge of Z$20-30. Doctors are very concerned abou t thesewom en, some of whom have had caesarian sections and require aminimum five-day stay to preven t com plications.User-fees lead to debtMany of the wom en w e interviewed have had to borrow moneyto go to the clinic. Litha Sibanda is a subsistence farmer whosehusband is working in South Africa. He sends small amounts ofmoney home infrequently. Litha grows millet, maize, andvegetables for her and her children to eat. She has been unable toproduce a surp lus for the last two seasons. Without a surp lus shecannot raise enough cash to buy basic necessities. She uses someof the money from her husband for essentials, and some is used topay the user-fees for her ch ildren's education. This leaves her nocash to pay for health care./ visited the clinic with headaches and abdom inal pain. It cost me $1 toregister at the clinic and $2 for the journey. I had to borrow the moneyfrom a friend, because 1 did not have any. I borrowed it because I thoughtit was serious, but otherwise I would not be able to .

Poor communications make matters worseAnother problem with the arbitrary implementation of user-feesand exemptions is that rural communication networks transmitthrough rumour what may be misleading information. Forexample, staff at St Paul's Mission Hospital told us of theirdistress when patients who would have been eligible forexemption attend with advanced diseases and severe pain,having been deterred from coming earlier by other villagers, whohad told them they would have to pay. While it is difficult togauge the precise effects of this confusion, in many areas it iscausing severe ill health and even death.One victim of the system is Brighton Simon, a five-year-old boyliving with his grandparents 25km from his nearest hospital or

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clinic. When we met him in St Paul's Mission Hospital, he waswasted and lethargic, his eyes dull. He was suffering frommarasmus, a form of protein malnutrition, and had been ill forsome time. When the doctor asked his grandmother why shedidn't bring him earlier, she replied: 'Because I thought wewould have to pay, and w e did n't have any money.' In reality thisfamily of agricultural labourers would have been exempt. But thefact w as that Brighton nearly died.Others are less fortunate. One mother told us of a child who haddied recently in Sigangatsha, South Matebeleland. This child'sillness had s tarted with a sore throat that his parents did not thinkserious enough to justify a journey to the clinic, because of thecost involved . He died the next day of mening itis.At St Paul's Mission Hospital the staff are able to use theirdiscretion and treat patients before asking for payment. Thispractice enables them to counter the adverse effects of charges.Ironically, their approach, which is protecting the access ofpatien ts to health services, is the very typ e of practice that w as socriticised by the World Bank in 1990 (World Bank, 1990).Prescription costs exclude poor peoplePrescription costs are ano ther factor w hich serve to exclude poorpeople. This was underlined by UNICEF's second sentinel sitesurvey (UN ICE F/GoZ, 1993a), which recorded that 31 per cent ofthose who needed treatment for asthma, hypertension, ordiabetes could no t afford the full course of treatm ent, while 66 percent of those w ho failed to com plete their treatm ent gave cost asthe reason.Among the women we interviewed, one of those receivinginadequate treatment because of prescription costs was MrsM ikwanda from Ny am arirwe Kubatana. She is an asthmatic, butunable to afford the Z$l per month for her Salbutamol tablets.

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Markets and accessSometimes my asthma gets very bad and the tablets are not strongenough. Then I must use an inhaler, but the hospital pharmacy does notkeep them, as they are so expensive. At the private pharmacy the cost isZ$46 for one inhaler, but I cannot pay that much , so I have to managewithout.If a person's d isease is classified as chronic, medication costs aresubsidised. At Hara re Central Hospital the subsidised cost is Z$3per item per month. Even th is cost is out of reach for many peop le.Yet it has been docum ented that some hospitals are still chargingthe full cost to patients. For an insulin-dependent diabetic, thismeans month ly paym ents of Z$158.84, a fee which only the verywealthy can afford.

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To improve health, invest ineducationAlongside declining expenditure on health, spending oneducation has been reduced, and user-fees considerablyincreased. Educational standards and enrolment levels are falling,with girls more affected than boys. This has serious im plicationsfor the health of the country, since higher levels of education bringhigher earning potential, which can lead in turn to better nutritionand health. Moreover, education for girls and women leads toespecially significant improvements in family health.The benefits of maternal education are particularly apparent inreduced rates of child mortality. Studies show impressivereductions, resulting from only one to three years of schooling.Women's education also has an indirect effect on family health,since educated girls are likely to marry w hen they are older, begintheir families later, make greater use of ante-natal care, and usemodern methods of contraception. Educated women are alsomore likely to be imm unised , to make use of medical services, toacquire and use health information, and to have better-nourishedchildren. A study in Cote d'lvoire found that 24 per cent ofchildren of mothers with no education were stunted, comparedwith 11 per cent of children of mothers with some elementaryschooling (World Bank, 1993). This partly reflects the higherincome levels of educated families. But education in itself isimportant in increasing income-generating op portun ities.Investment in education is decliningThe sharp fall in education spending after 1991 represents a causefor alarm, given the critical importance of the links between healthand education. Expenditure declined by 7 per cent in 1991 /92 and11 per cent in 1992/92 in real terms. The 1993/94 budgetannounced a 13 per cent increase for educa tion, equ ivalent to less32


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To improve health, invest in educationthan half the rate of inflation. At the same time, the num ber ofteachers has declined. As in the health sector, large numbers ofqualified staff are seeking work in the private sector or overseas,and teachers are rarely replaced. As a result, the pupil/teacherratio has increased by 5 per cent in primary schools.Alongside expenditure cuts, urban school fees were reintroducedin January 1992. Education costs for hou seho lds have increased ata time when household income has been eroded. As costs tofamilies have increased, there has been a corresponding decreasein the numbers of 'O' Level entries and the number of subjectentries per cand idate.Education costs are a regular burd en on the household economy.Even in the absence of direct school fees in rural prim ary schools,costs to parents of a child in primary school are still high, whenuniforms, spo rts fees, and the building levy are considered. In thecommunal and large-scale farming areas, the average cost peryear of primary education was Z$56 per pupil. Urban primary-school charges are particularly high, addin g up to a total of Z$160per year. In Binga district it costs Z$100 per term for secondaryeducation and bu ilding fees, plu s Z$60 for every 'O ' Level entry.Pay up or stay awayExemptions from school fees are available through the SocialDevelopment Fund for those on incomes of less than Z$400.However, the application system is complex, requiringcertificates which are frequently unavailable to parents. Oftenparents are not informed of the possibility of exemption.Of those parents w ho had not applied for he lp with school fees, 25per cent said they did not know about the Fund, 8 per cent saidthey knew about it but did not know how to apply , and 6 per centsaid the application process was too difficult.Of pupils applying for assistance, those in high-density neigh-bourhoods stood a better chance of having their applications

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accepted than pup ils in communal and resettlement areas. Forty-nine per cent of pupils in comm unal and resettlement areas whohad applied for assistance were still waiting for a response inApril 1993. These pup ils would either have had to pay in advanceor not attend school. Head-teachers find it hard to manageschools on tight budgets and cannot afford to wait for money toarrive from the Social Development Fund. They have no choicebut to dem and paym ent from paren ts or to refuse admission.There is plenty of evidence to show that charges for educationdeter people from sending their children to school. Surveys showthat 8 per cent of school age children had never been to school; thereason given for one third of these cases was lack of money(UNICEF/GoZ, 1993b). Ou r interviewees confirmed this broaderpicture. Mary Muleya lives alone with her three children inNsenga. She manages to send her three children to primary school:I only have to pay the building fund this year. My children can go as faras grade 7; then they must stop as I don't have any money; my husbandand I are divorced and there is no one to help me.Mrs Chapfiwa, another interviewee, lives in Rimbi in Manicalandand has four children at school. Her husband lost his job twoyears ago and they find it hard to keep their children at school:We have two children at Secondary school and have to pay Z$W 0 eachperterm. We got some forms from Social Welfare,but the school asked usto pay up-front. We managed to find the money this year. I don't knowhow we will find the money next time, but we w ill fight tooth and nail tokeep them at school.Evidence of gender-d eterm ined differences in health and educa-tion is contradictory, although it appears that girls are m ore likelyto be withdrawn from school before boys in the face of financialpressures. In Zimbabw e girls were found to be 85 per cent morelikely not to be in school than boys. Among those not in school,cost was mentioned more often for girls than for boys. Becausewomen's education and income are strongly related to familyand child health, the impact of girls' with drawal from school as aresult of charges will be significant.34


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Conclusion

The experience of Zimbabwe calls into question the seriousnesswith wh ich the W orld Bank has attem pted to integrate poverty-reduction mechanisms into structural adjustment. It alsoillustrates the grave dangers associated with the imposition ofideologically motivated prescriptions for financing healthsystems. Not only have user-fees in Zimbabwe provedinequitable: they have been grossly inefficient, even in the m ostnarrowly defined economic terms. Despite a considerableinvestment in collection mechanisms, health charges continue toaccount for less than 3 per cent of recurrent sp ending in the healthbudget, and in all probab ility the system constitutes a net drain onhealth resources, if administrative costs are taken into account.This points to the central dilemma in introducing user-fees intohealth systems which serve populations characterised by highdegrees of poverty : namely, that retu rns to fees decline and costsof administration rise in proportion to the size of the populationwhich qualifies for exemption. For many rural hospitals inZimbabwe, around 90 per cent of patients would qualify forexem ption, were the systems functioning effectively.Considerations of equity and efficiency therefore both pointoverwhelmingly towards a case for withdrawing user-fees.Unfortunately, the Zimbabw e gov ernm ent's policy is pulling inprecisely the opposite direction, as witnessed by the sharpincrease in user-fees in January 1994. Ante-natal fees alone wereincreased from between $Z10-12 to $Z50-60 at district hospitals,and out-patient fees from $Z1.50 to $Z17. If the evidence from thewomen interviewed for this report is an accurate guide, it isinevitable that these increases will impose considerable socialcosts on highly vulnerable populations.Against this background, there is an increasingly compelling casefor the World Bank to translate its rhetorical commitment to

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poverty reduction into concrete policy initiatives. Havinginitially endorsed the case for user-fees, the Bank has aresponsibility to use its influence to press for their with drawal. Itcould do so most effectively by demanding the phased with-drawal of user-fees over the lifetime of the adjustmentprogramme. Failure to do so will leave the poorest and mostvulnerable sections of Zimbabwean society facing unacceptablesocial costs. And the World Bank and IMF's frequent commit-ments to poverty-reducing adjustment strategies in the healthsector will remain what they are at present: empty words,designed to impress donors and mislead public opinion aboutthe real costs of adjustment.

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SourcesAkin, J et al. (1987): Financing Health Services in Developing

Countries. A World Bank Policy Study, Washington: World BankCh isvo, M (1993): Government Spending on Social Services and the

Impact of Structural Adjustment in Zimbabw e, Harare : UNICEFCommonwealth Secretariat (1989): Engendering Adjustment for

the 1990s: Report of a Com monw ealth Expert G roup on Wom en andStructural Adjustment, London: Com monwealth Secretariat

Iliff, P (1992): 'A Case for Exempting all Maternity Patients fromHealth Services Charg es', University of Zimbabw e M edicalSchool: mimeoKanji and Jazdowska (1993): 'Seminar on the Gender-specificEffects of ESAP on Households in Kambuzuma', Harare:mimeoLennock, J (1994): 'Health Planning and Financing', LondonSchool of Economics: mimeoMutambirwa, J (1989): 'Health problems in rural communities,Zimbabwe', Social Science and Medicine, Vol 29, No 8 :927-32Renfrew, A (1992): ESAP and Health, Harare: Mambo PressSave the Children (1993): Nutritional and Health Status of Young

Children and Household Level Food Security During a SevereDrought in Zimbabwe, Ha rare: SCF

UNICEF/Government of Zimbabwe (1992): Findings from theFirst Round of Sentinel Surveillance for Social Dimensions ofAdjustment Monitoring, Harare : GoZ

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Paying for HealthUNICEF/Government of Zimbabwe (1993a): Findings from the

Second Round of Sentinel Surveillance for Social Dimensions ofAdjustment Monitoring, Harare : GoZ

UNICEF/Government of Zimbabwe (1993b): Findings from theThird Round of Sentinel Surveillance for Social Dimensions ofAdjustment Monitoring, Harare : GoZ

World Bank (1990): Zimbabwe: issues in the Financing of HealthServices, W ashington: World Bank

World Bank (1992): Improving the Implementation of Cost Recoveryfor Health: Lessons from Zimbabwe, Washington: World Bank

World Bank (1993): World Development Report 1993, Oxford:Oxford University Press

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Further reading from Oxfam

Financing Health CareHilary Goodman and Catriona WaddingtonOxfam Practical Health Guide No. 81993,96 pages, paperback , ISBN 0 85598187 3Using examples from many parts of the world, the authorsconsider a range of financial structures which have beenimplem ented in response to a variety of comm unity health-careneeds.A Simple Guide to Structural AdjustmentJohn Clark w ith M ary Da vies1991,32 pages, paperback, ISBN 0 85598 184 9What is 'structural adjustmen t'? Why is it controversial? W hat areits social implications? Is there any a lternative for impoverishedcountries struggling to balance their budgets? The authorsprovide a basic introduction for the general reader.Zimbabwe: A Land DividedAn Oxfam Country ProfileRobin Palmer and Isobel Birch1992,64 pages, paperback, ISBN 0 85598 178 4This book examines the record of the governm ent of Zim babw eten years after independence, showing its early successes inimprov ing health care and education, and analysing the politicaland economic stresses which impede the creation of a fair societywith equal opportunities for all.

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Documents

Paying for Health: Poverty and structural adjustment in Zimbabwe