The halls of Parirenyatwa, Zimbabwe's main referral hospital, which is in Harare, are quiet most afternoons. At 2pm, when visiting hours are over, the streams of friends and family that overwhelm its main arteries begin to trail off, leaving only a few stragglers who wait for visiting times to begin again.
One of these is a fortysomething woman who is waiting to hear news of her uncle: he has been admitted for a broken leg suffered in a car crash. Speaking quietly, she says that he has been in hospital for only two days but already the out-of-pocket bill is more than $300.
"Everything [he's] using, we have to pay for it. The drugs, the drip, everything."
She is oddly calm throughout most of our conversation but panics when she thinks about the bills.
"He's the breadwinner … how are we going to pay for this?"
She says her uncle has yet to see a doctor.
Although independent Zimbabwe has always required patients to pay, during the 1980s those who made less than $400 a year, pregnant women, children under five and people over 65 were exempt.
Troubled economic times
But things have changed. Itai Rusike, executive director of the Community Working Group on Health, a network of Zimbabwean health organisations, says that –beginning in the 1990s, when the country implemented its Economic Structural Adjustment Programme (ESAP) – Zimbabwe has cut down on public spending and nearly every-one, regardless of age or income, was required to pay fees. The situation deteriorated during the country's troubled economic times of the 2000s.
Today, with the government cash-strapped, local authorities, who are responsible for running most of the country's public medical institutions, are no longer able to rely on national government grants. Instead they look to fees in order to make ends meet.
The rates vary depending on the type of healthcare centre, where it's located and the service offered. In most urban centres, the official delivery fee for expectant mothers is $25, says Rusike, but, according to policy, delivery is meant to be free in rural areas. However, some struggling, destitute institutions charge anything between $10 and $30.
But the real price tag can be dramatically increased by medicine costs, fees for hospital beds, expensive procedures and corruption – patients told Bhekisisa that it's not unusual to pay to skip long queues.
Those waiting outside Parirenyatwa say they or their family members paid about $400 for a baby's delivery, medicine and hospital stay.
One woman says she was able to pay only $120 of her $380 bill, and had to obtain a police affidavit stating that she would pay the rest before she could be discharged.
One man, visiting his wife and newborn child, says he forks out $500 each month in medical bills.
User fees have had a tremendous impact on health outcomes in Zimbabwe. According to the country's 2010-2011 demographic health survey, eight women die every day of pregnancy-related causes. The World Health Organisation (WHO) says that, in 2010, 570 Zimbabwean mothers died for every 100 000 who gave birth. Compare that with South Africa, where in the same year the WHO estimates that 300 mothers died for every 100 000 live births.
These figures tell a chilling tale about the strength of the overall health system. In a 2007 issue of the influential United States-based international relations magazine Foreign Affairs, Pulitzer Prize-winning health author Laurie Garret writes: "Maternal mortality data is said to be an important indicator of overall health system quality because pregnant women survive in sanitary, safe, well-staffed and stocked facilities. If new mothers are thriving, it indicates that the healthcare system is doing its job. If not, problems likely exist."
Rusike says that one-third of expectant Zimbabwean mothers, unable to afford user fees or to reach faraway health centres, give birth at home. If something goes wrong, they often get help too late.
Many blame the country's ESAP for the degradation of the health system.
"Zimbabwe used to have the best system in the region; we were a success story," says Rusike. "But then, with structural adjustment, Zimbabwe had to cut back on public spending."
The World Bank, which supported the country's ESAP by providing loans, says that, because of the country's strong focus on public programmes post-independence in the 1980s, 45% of its gross domestic product stemmed from public expenditure. Considering this unsustainable, the country began to institute reforms in 1991, which included cutting down public-sector spending.
Damaged health system
According to a 1996 article analysing the impact of Zimbabwe's ESAP programme, published in the Southern African Report, a bulletin covering economic and political issues in the Southern African Development Community, "public expenditure on healthcare declined by 39% in 1994-1995 … At the same time, the government's stricter enforcement of a user-fees system erected barriers to healthcare."
The article states that pregnancy-related deaths increased and that drug stock-outs were common.
"In 1992, doctors and nurses began referring to 'ESAP deaths', described as deaths caused by the inability of patients to pay for the minimal length of time in the hospital, or for prescription medicine."
Others blame the country's damaged health system on the dire economic situation of the 2 000s, characterised by hyperinflation and divestment. The effect on the health system was devastating and cyclical, says Ruth Bonde, chairperson of the Zimbabwean Association of Doctors for Human Rights – the worse the economy became, the higher unemployment became, thus shrinking the tax base and reducing government funding, which led to individual institutions requiring the payment of fees for public services – fees that had to be paid by an increasingly poor and desperate public.
During the crisis, Bonde says that, like other well-educated workers, many healthcare staff left Zimbabwe, looking for opportunities elsewhere.
Today, there is a concerted effort to stem rising health costs. In the past few years, after Zimbabwe adopted the US dollar and the government of national unity was formed – both of which marked a move towards economic and political stability – donors flooded into the country, says both Rusike and Bonde.
In 2011, the United Nations Children's Fund and the government of Zimbabwe set up a health transition fund (HTF), with funding primarily stemming from the United Kingdom and the European Union. Among other things, it aims to eliminate maternal and child health fees at some health centres. The World Bank has also set up a results-based financing (RBF) programme, which gives financial rewards to health centres that meet certain goals. Both are aimed at the rural areas, where, Rusike says, patients travel up to 300km to access one of the few health centres run by the national government, benefit from donor funds or are under the management of a church mission and don't charge fees.
Although both the HTF and RBF are finite – the former is meant to end in 2015 and the latter is expected to close in 2014 – it is hoped that they will help to get the health system back on its feet.
But more donors doesn't necessarily mean a better health programme overall. Bonde says that a disease-specific focus by some donors, such as the Global Fund to Fight Aids, Tuberculosis and Malaria, has resulted in "an increase in the availability of some drugs [but] the health system is still really weak. We have a functioning treatment system [for these diseases] but in a dysfunctional system."
The country's malaria programme offers some insight. Archaically, the country still uses DDT to control mosquitoes. This, Bonde says, is because the pesticide, banned in most countries because of its negative impacts on human health and the environment, is cheap. But, she says, "case detection is going well, because it's done through Global Fund-distributed rapid test kits."
Critics say that health has taken a backseat to other priorities, and that donors are unwillingly complicit in this skewed resourcing. According to a disgruntled young Zimbabwean, who asked not to be named as he works for an international organisation: "If you look at [Zimbabwe's] budgets and the way they allocate funds, most of it goes to military staff and agriculture, and health is the last thing they think about. They know that if people die … so-and-so is going to come and fund it … It's causing our government not to take responsibility for something they should."
Rusike says that, instead of appealing to outside sources, Zimbabwe should pledge 15% of its total budget to health, as undertaken by all African countries in Abuja in 2001 at a meeting of health ministers.
"The 2013 budget allocation of [$381-million] is 11.4% of the total national budget, a huge increase compared to the previous year, but still short of the Abuja target," says Rusike. "Sadly, if we remove the Chinese loan of $98-million [for medical equipment], the percentage further goes down to … 9.8%."