“It’s much more than we can cope”– Zimbabwe’s Collapsed Health Care System

The MSF supported HIV clinic in Epworth, a satellite town to Zimbabwe’s capital city, has doctors, nurses, drugs, supplies – it is working and it is free. A rarity in today’s Zimbabwe, where the national health system is basically dysfunctional.

After more than one year without real salaries – inflation made salaries into almost worthless equivalents – health staff of Zimbabwean hospitals and clinics began staying away since last November, leaving behind almost empty clinics, lacking basic supplies and unable to provide adequate care. Recently, some of the staff has returned
after receiving allowances and food vouchers. However, according to a report of the Zimbabwean Ministry of Finance and Welfare from March 2009, 68 percent of all doctor’s posts and even 80 percent of the nurse midwife positions are still vacant. Health facilities still functioning have begun charging in US dollars, making it completely unreachable for the majority of the Zimbabwean population.

Yet, MSF services in the Epworth clinic are for HIV+ patients. “There is a feeling, certainly here in Epworth, that it is better to be HIV positive than HIV negative,” says Melanie Rosenvinge, MSF doctor working in MSF’s Epworth Project. “You certainly will have better access to health care.” Without any referral options, MSF in Epworth began taking care of all patients in their daycare facility. The consequence was an uncontrollable increase in patients. “The clinic was really congested with lots of very sick patients and a high death rate,” says Stefanie Dressler, Coordinator for Epworth project. “People come here at the gate, they bring dying patients saying ‘please help us we don’t find any other place,’ but we can’t help everyone, we can’t,” says Stephanie regretfully.

Feeling the impact of the collapsed system

The MSF HIV Project in Gweru, a city in southwestern Zimbabwe, is also feeling the impact of the collapsing public health system – yet because some patients aren’t getting to them. “We have seen a huge impact on our PMTCT program,” says Claudia Stephan, the Project’s Coordinator. PMTCT, short for “Prevention of Mother to Child Transmission”, aims to help HIV+ mothers from transmitting the virus to their unborn children. For MSF to enroll pregnant women in this program, they have to have access to them before they give birth. In the clinics, they have to be booked for antenatal care (ANC) which also has to be paid in USD. “Some weeks, there was only one woman booked for ANC,” says Claudia explaining that because the public health clinics are charging in foreign currency the women don’t even come to the clinic nowadays. “If we do not find a solution this is a disaster for the PMTCT program,” says Claudia.

The new fees charged across the country are completely unattainable for most Zimbabweans. In Chitungwiza, the closest functional hospital to Epworth, the public health system is charging 8 USD for a simple consultation, while for an overnight stay it comes to 48 USD. And everything has to be paid for by the patient, even the use of a pair of gloves by a nurse, which costs 2 USD or an IV fluid 20 USD.

A majority of Zimbabweans earn less than 30 USD a month, an income that if it exists will usually have to support a large extended family. But many have never even been able to access a foreign currency income. “People here, they don’t even know the [US$] dollar,” says Mary, 57, a resident on the outskirts of Harare, and a volunteer with MSF. “They don’t ever see it, don’t even know its color,” she says emphatically. 

HIV in massive numbers
 
Zimbabwe’s health system collapse has happened at a time when its people are suffering under its history’s worse health crisis. The official HIV rate is 18 percent but in the areas where MSF works the unofficial estimate is much higher, certainly more than 20 percent. That means that just in a place like Epworth, 120,000 are probably HIV+, while half of these need to start on Anti-Retroviral Treatment (ART) immediately. MSF in Epworth has registered over 10,000 patients of whom over 7,000 are under constant care. “If you do the simple math,” says the Project’s Coordinator, “it is much more than we can cope.”

And those living in Epworth are the lucky ones. “They try to sneak in from all over Harare,” says Stefanie explaining that people from other areas pay some dollars to someone living in Epworth in order to claim they live there. MSF by agreement from the Ministry of Health only has a mandate for Epworth. “They are desperate,” points out Stefanie.

Veronica , 37, has four children and lives in Kwadzana, a satellite township to Harare. Her husband died last year with all the symptoms of AIDS, though he never went to the hospital to confirm his illness. “I want to get tested and start on ARVs,” says Veronica conscious that if something happens to her there will be nobody to take care of her kids. Yet for her to start on ARVs she would have to pay to get the so-called CD4 count test done, which shows how badly a patient is affected by the virus and whether or not anti retroviral treatment was necessary. She and her sister, with eight kids between them can only make at most 20USD a month by selling vegetables and fish at the market.

Just recovered from cholera

But another epidemic has scourged the country this past year. Veronica and five other people in her household have also just recovered from cholera. Cholera has hit Zimbabwe in unimaginable magnitude. At present, according to WHO estimates from April 14, 96,300 people have been affected in the country, 4195 have died of cholera. MSF has been able to provide many of these people with care in dozens of cholera treatment centers (CTCs) around the country. Yet, here as well, the collapse of the health infrastructure is strongly felt.

“Everywhere in all the CTCs it is the same,” says Heidi Lehnen, MSF nurse with the Cholera Emergency Team. “They try to sneak in the CTCs to get some medications even when they don’t have cholera,” she explains. “Why? Because we actually treat people.” Liliosa, a national MSF nurse working at one of Harare’s CTCs agrees. “People would come just for antibiotics or anything – they would beg for admission,” she says but points out that they wouldn’t be able to let them in because they had to keep it strictly for cholera patients.

Malnutrition

Coupled with these epidemics and aggravating the situation is the fact that many Zimbabweans are suffering from malnutrition – especially obvious in the children. Epworth began a Therapeutic Feeding Center (TFC) two years ago but this year the number of children has doubled, especially during this peak season between November and March, when people wait for the harvest. “At least one or two will die each week,” says Michele, MSF nurse in charge of the TFC, as she surveys the close to 30 small children under her care just that day. Half the kids have feeding tubes. Michele explains that it is necessary because they are so absolutely malnourished that their system has shut down completely and they refuse to eat. Most weeks they will care for between 400 to 600 malnourished children a week.

Melanie, the MSF doctor over at the clinic taking care of the HIV patients, says that especially the deaths of the children, sometimes one or two a day, is the hardest for her to deal with. “The first child I saw that died was a 7-year old girl and there was nothing I could do about it” she says. “It is traumatic but you just have to harden yourself a bit, you have to say I’ve tried my best in the current situation and at the end of the day it is not my fault that the health care structure as a whole has disintegrated like it has.”

Dysfunctional Morgues

Possibly dying patients have an additional trauma in the current non-functioning health structure. “Gweru Provincial Hospital rejects patients that might die because their morgue is not functioning and bodies are left behind for days until the relatives can find the money,” says Claudia, MSF’s Project Coordinator in Gweru. “Because of this they don’t want anyone dying in their hospital,” explains Claudia.

Epworth has the same problem. The referral hospital where they are suppose to send cases is actually in another town to Epworth and it costs at least $4 USD to get there. Most patients are brought to Epworth clinic by their relatives pushing them in wheelbarrows. “I have to ask the relatives,” says Melanie the Epworth doctor, “whether if their person dies, if they will have the money to transport the body back – you can imagine how awful that is.”

Melanie has to focus on the patients that get better, like Pamela, an HIV+ woman that started her treatment at Epworth last year. “I almost burst into tears when I saw her,” says Melanie recalling the day when Pamela came walking to greet her. She had been in bed for a year and four months. When Melanie first studied her results she didn’t have any white blood cells at all. Today she is healthy. “There are so many,” says Melanie, “but there are people that you do treat and they do get better. You have to focus on them.”