… Addressing Zimbabwe’s Health System Demise and Brain Drain
By Itai Rusike
This article was first published in the Medicus Mundi Switzerland (MMS) Bulletin, #172 March 2025
The health and social services must function optimally for a country to realize social cohesion, economic growth, and be in tandem with the global health and security agenda. The current situation of investing in education and professional training and then “donating” the young and able-bodied products to already established, functional health systems located in wealthy countries is a luxury that poor economies like Zimbabwe cannot afford. The remaining few health workers remain frustrated and incapacitated to deliver effective care resulting in the subdued population health status currently obtaining in Zimbabwe.
CHWs in Zimbabwe participating at the National Health Financing Dialogue – @Itai Rusike
The development and transition of the health system in Zimbabwe over the decades
Zimbabwe has documented a number of transitions in its healthcare delivery system. In the pre-colonial era and before introduction of conventional medicine, traditional and spiritual methods of diagnosis and treatments were complemented by diets and taboos that supported the health across the life course. There were specific foods and medicinal plants for the pregnant women, newborns, young children, adolescents, young adults and the elderly. Various medicine men and women and the older uncles and aunts would oversee these, but there were no formally trained health professionals.
The colonial era came with introduction of western medicine but was limited mostly to the urban, mining and agricultural areas, and left the rural areas to continue their various traditional medical practices to address ailments. This saw the introduction of formal training of the natives in health especially nursing, environmental health to complement those introduced by the settlers. The first African Zimbabwean doctor was Samuel Parirenyatwa.
At its Independence in 1980, and just two years after the Alma Ata Declaration the government premised its health delivery system on the concept and philosophy of Primary Health Care (PHC) (WHO, UNICEF, 1978); greatly expanding the reach of conventional medicine to the rest of the country in terms of more health institutions and a defined healthcare workforce for the public health system, to be followed by a health workforce “establishment”. This was after the realization that the majority of the population resided in the rural areas and yet health care was centralized in the few urban centers. A number of policy pronouncements guided the process of ensuring the goal of “health for all by 2000”; including the white paper on health of 1981, “Planning for Equity in Health” of 1985, and the accompanying decentralization saw much improvement in the population access to affordable and quality health care.
In the 1997-2007 national health strategy, 85% of the population had access to a health facility within 10Km. The public health system catered for about 80% of the population through central government, local government, church and NGO run institutions. The life expectancy, maternal, child and general mortality in the population greatly reduced while health status and other favorable indicators improved leading to the country attaining notable health and welfare standards.
At its Independence in 1980, and just two years after the Alma Ata Declaration the government premised its health delivery system on the concept and philosophy of Primary Health Care (PHC).
Current situation
A number of challenges have almost reversed this progress and development of Zimbabwe’s health sector of which have been decades of socio-economic and political challenges that impacted negatively on health and related social services. These have been compounded by weaknesses within the system characterized by rigidity within the governance and management levels and resultant failures to adapt to the changes. The health workforce bear the brunt of these systemic weaknesses and failures and so after the demise of almost all the health system building blocks trained and experienced staff have been leaving in large numbers to join the private sector, neighboring countries and the diaspora. The major complaints have been poor remuneration, limited access to tools of the trade, as the health institutions continue to have stock outs of medicines and major supplies.
The weak governance systems also mean that there is no organized systems to adequately plan for and deploy the few trained personnel to benefit their populations, nor benefit the country when they emigrate to other countries.
The country and health system failed to adequately adopt to major transitions and have left healthcare workers with little or no support in terms of capacitation to cope, protection from infections within institutions and during public health crises, nor financial cover to make their work and contribution worthwhile. Among the transitions have been the structural adjustment programs, (ESAP) of the mid 1980’s, the HIV pandemic of the early 1990’s, and now the socioeconomic and political situation since the turn of the millennium. There have also been demographic, epidemiological and technological transitions in line with population increases, disease trends and this combination of major changes required a corresponding governance and management structure that responds with timely and effective policy and legislative responses that ensure sustainable service delivery with the health workforce at the center- being a services sector.
However the decentralization of early 1990’s was not followed by devolution and healthcare worker issues have continued to be centralized, fueling frustration and health worker exodus and thus almost emptying the institutions of their health workforce.
Despite progressive increases in budgetary allocations towards the 15% allocation for health, (Abuja, 2001), the fiscal disbursements have been inadequate to keep the system afloat. The 15% mark has never been attained, with Government spending on health care as a percentage of total public expenditure increasing only from 10.6% in 2022 to 11.2% in 2023.
This poor financing for health has been another sore issue for the health workers as they interface with clients they cannot adequately serve. The majority of clients seen in the public sector remain without comprehensive care except for a few selected diseases and conditions which receive vertical funding (HIV/Aids, TB, Malaria, maternal and child conditions). Despite the recent moves to integration Health Communitiy Workers (HCWs) get frustrated rendering inadequate service and have therefore been moving to more resourced jurisdictions.
This situation means that universal access to health remains beyond reach, until and unless the complex health situation is effectively addressed. The recent developments of wars, climate crises and the major shifts in the donor landscape well before the earlier warning of the 2030 deadline requires urgent action on the part of government and the health ministry.
The majority of clients seen in the public sector remain without comprehensive care except for a few selected diseases and conditions which receive vertical funding (HIV/Aids, TB, Malaria, maternal and child conditions).
Causes of the global health care workforce shortages
A number of factors are responsible for the current situation including the demographic and epidemic transitions. The inadequate health workforce in developed countries cannot cope with the combined complexities of chronic diseases compounded by ageing populations. Meanwhile in developing countries it’s the opposite in that the epidemiological transition has not been effectively addressed as they remain with a huge burden of infections, emerging and re-emerging diseases, unchecked chronic/noncommunicable diseases which include injuries, mental health conditions and substance abuse.
The demographics are characteristically young populations but with limited access to education and training opportunities due to weak health, education and other social systems. The weak governance systems also mean that there is no organized system to adequately plan for and deploy the few trained personnel to benefit their populations, nor benefit the country when they emigrate to other countries. The case in point being that of the expatriates deployed to Zimbabwe during the post-independence era and in recent times, the Cuban health, education etc brigades whose deployment is regulated by their state, and follows signed agreements with the receiving countries. The World Health Organization (WHO) Global code on recruitment of health care workers has not been heeded, neither is it enforceable in the member states as is the framework convention on tobacco control, (FCTC) and the international health regulations, (IHR, 2005, 20012), both of which are binding.
The current situation of investing in education and professional training and then “donating” the young and able-bodied products to already established, functional health systems located in wealthy countries is a luxury that poor economies like Zimbabwe cannot afford.
Social and economic consequences of a shortage of HCWs for countries with weaker health systems
In Zimbabwe, the past two decades have been characterized by massive outward migration of health, education, social and other professionals due to the protracted social political and economic demise. This state of affairs has greatly impacted on government’s functionality with the high levels of corruption taking resources away from where they are needed most. The results have been telling in the multi system collapse including public health infrastructure and services.
As a result, the major determinants of health have become severely neglected, causing outbreaks and adding a considerable burden of preventable diseases and conditions. For a largely unemployed population, the paradox is the huge out of pocket expenditure for preventable ailments while the collapsed system cannot serve the clients. The result has been adverse health indicators across the population with considerable premature, avoidable and excess mortality.
How do HCWs experience the effects of staff shortage?
Healthcare workers are supposed to work as teams and seldom in isolation. At central, city and provincial hospitals there used to be multidisciplinary teams of 2-4 consultants per firm, with registrars, senior and junior residents, then the nursing team, physiotherapists, nutritionist etc., but currently there may just be one doctor -and few nurses. The workload becomes unmanageable and each shift is taxing as oftentimes one cadre has to carry out the tasks of 3 or 4 others, with no one to discuss the patient condition, treatment options nor debrief.
This has resulted in burnout of the few cadres whose recognition and remuneration has not increased significantly despite the increased demand on them. The patients and their relatives often accuse them of blocking services and pilfering medicines and supplies for their benefit when in fact it’s the nationwide corruption that has stripped the system and caused the neglect. At the districts and remote clinics often one nurse has to oversee a whole unit and this compromises patient care, accurate documentation and patient follow up. There is little time for continuous professional development as most of the time the staff is overwhelmed and working solo.
The patients and their relatives often accuse them of blocking services and pilfering medicines and supplies for their benefit when in fact it’s the nationwide corruption that has stripped the system and caused the neglect.
How effective is the WHO Global Code of Practice on international recruitment of HCWs?
For countries like Zimbabwe the global and even the WHO Afro regional office pronouncements on preventing or minimizing health worker migration have been ineffective. There has to be some acknowledgment to the sending country to compensate for its investment in the professional and this to be ring-fenced to further enable training and or improving the working environment of those who remain in-country. Deliberate efforts must be made to invest in addressing the demise of the health systems that have bled too many healthcare workers by the major receiving and wealthy nations.
There has to be some acknowledgment to the sending country to compensate for its investment in the professional and this to be ring-fenced to further enable training and or improving the working environment of those who remain in-country.
What are the potential solutions to address HCWs crisis/shortage long term?
– Address the work environment by re-investing and revitalizing the health delivery system across the WHO’s six building blocks of a health delivery system, and in tandem with a revitalized primary health care for universal health access (PHC4UHC, CWGH, PHCPI, 2022).
– Implement the health financing reform in line with the dwindling donor support and the critical need for a robust local financing architecture.
– Improve the governance and management of the healthcare workforce and ensure that well trained health professionals are in charge and make decisions rather than the corruptly appointed management.
The latter have been competing with and further frustrating the healthcare workers and yet remain without a sound understanding of the system and its complexities. Given the extent of the demise and the high turnover of staff over a protracted period, there may be need to bring in some of the old guard, (retired but not tired) to hand hold and mentor the young inexperienced staff. This can help restore the dignity of the profession, improve confidence, service delivery and patient outcomes.
The government must also ensure implementation of the Constitutional provisions for health and its determinants, enforce the public health act and enforce mandates across all sectors that hold key determinants of health in order to effectively prevent disease and promote health. The result will be more manageable workloads for the reduced staff. Furthermore, there has to be strategies that address the huge and unchecked burden of non-communicable diseases, injuries and mass trauma casualties, mental health, substance abuse and climate induced health issues that have not yet received attention but are over-loading the limited health workforce.
Itai Rusike is the Executive Director, Community Working Group on Health (CWGH) – Zimbabwe. Itai is a Public Health Activist with more than 20 years’ experience organising involvement of communities in health actions in Zimbabwe. He is a member and chairperson of various health related committees, along with being the Vice-President of Medicus Mundi International Network.
For the full bulletin, follow link : https://www.medicusmundi.ch/en/advocacy/publications/mms-bulletin/health-workforce-shortage-are-there-potential/kapitel-1/addressing-zimbabwe%E2%80%99s-health-system-demise
