Zim: Health and education bounce back
Zimbabwe can hasten its recovery by abolishing user fees and expanding its fiscal resources.
The breakdown in Zimbabwe’s social sector in the last two decades is well documented but less known is the painstaking work that has gone into rebuilding them to something akin to the 1980s. Nothing symbolises the breakdown more than the cholera outbreak of 2008 which claimed 4 000 lives and left 100 000 people battling for their lives. Since then, there has been no such catastrophe despite the existence of all the conditions ideal for major disease outbreaks. What has happened?
At independence in 1980, Zimbabwe’s real GDP growth averaged 4% per annum, reaching a peak of 7% in 1990. Huge amounts were invested in health and education and expansion of rural infrastructure, with the aim of reducing inequalities. A strong social system was the result and could be the reason that Zimbabwe’s health and education sectors retained the ability to bounce back from the abyss.
The introduction of economic reforms in the 1990s, including user fees in health and education, began to reverse the earlier gains, with severe ramifications for the poor. From the mid-1990s onwards, real GDP growth averaged only 1.5% per annum and by 2008, economic growth was well ensconced in negative territory.
The education system, arguably one of the best on the continent, faltered badly. Although enrolment rates remained high, examination pass rates and other indicators of quality were plummeting. In the absence of significant central government financing, a complex system of fees, levies and so-called incentives evolved that further disadvantaged the poor. Every year, half of the students who had completed primary school could not proceed to secondary school.
The once robust healthcare system also weakened badly. Maternal mortality tripled and under-five mortality increased by more than 20%. The government’s social protection systems that had functioned so well previously fell away.
Funds set up
The formation of the unity government and introduction of multiple currencies in 2009 stopped hyperinflation and ignited economic recovery, albeit from a depleted base. The scale of the social decline required an equally large-scale national response. Using its experience in managing previous multi-donor funds, the United Nations Children’s Fund (Unicef) convinced the government and donors to set up pool funds to which everybody would contribute.
Funds were set up in child protection, health, education, and water and sanitation. These mechanisms promote joint programming between the government, donors and other development players, use national systems for procurement, and have strong monitoring and financial management systems.
The decline in social indicators has been halted and there is a measure of stability in the provision of essential services. There are also fewer deaths among pregnant women and young children. Zimbabwe’s census places maternal mortality at 525 deaths per 100 000 live births in 2012 from a high of 1 068 in 2002.
Decline in maternal deaths
A United Nations group that monitors mortality says maternal deaths have declined from 740 deaths per 100 000 live births in 2005 to 470 deaths per 100 000 live births in 2013. Similarly, mortality in under-five children has fallen from 97 deaths per 1 000 live births in 2009 to 88 deaths per 1 000 live births in 2013. HIV prevalence among adults has also declined by half.
What can reasonably be inferred from this declining trend? First, the resilience of the systems developed after independence not only kept the sectors afloat, albeit thinly, but also enabled a quick rebound when the situation stabilised.
Second, there have been rigorous efforts by the government, donors and other development players to get the systems working again through building up human resources, repairing broken infrastructure, and providing essential supplies.
Monthly top-up allowances given to 18 800 health personnel have not only stopped the haemorrhage of skilled staff but are also attracting those who had left. The number of doctors in district hospitals has increased from 70 in 2011 to 126 in 2013, and 1 800 new midwives have been trained.
Hospitals and clinics are better stocked with essential medicines, blood and other medical essentials.
Construction and rehabilitation of water and sanitation facilities in 14 small towns and 33 rural districts provide clean water and safer sanitation to millions, thereby reducing the risk of diseases.
If the cholera outbreak of 2008 was symptomatic of the breakdown, that only six cases of cholera were reported during this year’s heavy rains may signal progress.
Every pupil now has a textbook in core subjects, while efforts are under way to improve quality through school improvement grants, training of teachers, and curriculum review. Grade 7 pass rates, which had dropped from 70% in 2007 to 40% in 2009, are slowly creeping up.
About 100 000 children from poor households are benefitting from monthly social cash transfers and access to justice and welfare services for children exposed to violence is being expanded.
How can Zimbabwe truly sustain these gains? The recent budgetary increases for the social sector are welcome, but they still remain below historical levels. The funding is also primarily for salaries, with almost nothing left over for other critical needs. This means donors and economically hard-pressed families continue to finance the gaps.
With economic and fiscal recovery, the government should embark on progressively abolishing user fees and financing the gaps through general taxation. User fees are regressive and unfair as they mostly exclude the poor.
While it may be difficult in the short term, the government can begin by reducing these fees, either across the board or through targeted subsidies in key areas such as maternal and child health, and in primary education.
The private sector, in particular the extractive industry, and local communities can also play their role. There needs to be a comprehensive private-public partnership that spells out the win-wins for both parties.
Local manufacturers can also supply goods and services to the education and health sectors, but their capacity needs to improve. Communities too can be involved in managing facilities and services and contributing in kind to the rebuilding of social infrastructure.
Reza Hossaini is the Unicef Zimbabwe representative and writes this exclusively for the Mail & Guardian.