COLLAPSE: ZIMBABWE'S HEALTH CARE SYSTEM

C O N F I D E N T I A L SECTION 01 OF 15 HARARE 001039 SIPDIS AF/S FOR B. WALCH MED/EX FOR T. YUN AND G. PENNER CA/OCS FOR E. GRACON DRL FOR N. WILETT OGAC FOR M. DYBUL, J. TIMBERLAKE, T. HIMMELFARB, C. HOLMES JOHANNESBURG FOR M. VEASY PRETORIA FOR H. HALE, P. DISKIN, AND S. MCNIVEN GABARONE FOR A. WOODS ADDIS ABABA FOR USAU ADDIS ABABA FOR ACSS STATE PASS TO USAID FOR E. LOKEN, L. DOBBINS, K. LUU, A. CONVERY, L.M. THOMAS, T. DENYSENKO, J. BORNS, A. SINK, L. PETERSEN STATE PASS TO NSC FOR SENIOR AFRICA DIRECTOR B. PITTMAN STATE PASS TO HHS FOR W.STEIGER, S. BLOUNT, AND D. BIRX E.O. 12958: DECL: 11/20/2018 TAGS: SOCI EAID AMED PGOV CACS PHUM ZI SUBJECT: COLLAPSE: ZIMBABWE'S HEALTH CARE SYSTEM REF: HARARE 1007 Classified By: Ambassador James McGee for reason 1.4 (b) and (d). -------------- SUMMARY -------------- ¶1. (SBU) Zimbabwe's health system has collapsed. Most of Zimbabwe's public hospitals, including the three main medical centers in Harare, are closed. Many clinics lack basics including staff, water, electricity, and medical supplies. Despite protests by medical professionals and outcry over the cholera outbreaks that are quickly spreading across the country, the Zimbabwean government is unable to provide basic health care services or maintain public service infrastructure (e.g. water, sewers, power) and increasingly relies on donors and NGOs for help. Even NGOs, however, are finding they cannot provide medical care to their own staff, as medical insurance is now defunct and the only way to access care in Harare is through private practitioners who universally demand U.S. dollars, in cash, up front for payment. Ambulance services that typically rely on medical insurance as their primary source of income are also struggling to stay afloat. As the economy continues to collapse, there is no end in sight to the woes facing the health sector. Given the rapidly deteriorating environment, we must reconsider how we do business both in terms of our humanitarian assistance and our plans to provide medical care to our own mission staff. END SUMMARY. -------------- Harare's Public Hospitals: Officially Open, but Functionally Closed -------------- ¶2. (SBU) Harare province is home to three major public hospitals: Harare Central Hospital, Parirenyatwa Hospital, and Chitungwiza Hospital. In a meeting with donors on November 18, CEOs of all three hospitals described the overwhelming difficulties they face. All three described a serious crisis including staffing issues, infrastructure problems, shortages of linen and medical supplies, hungry staff, and a host of other problems that remain unaddressed by the Zimbabwean government (GOZ). ¶3. (SBU) Up until about 2000, all three of these hospitals provided some of the best care in sub-Saharan Africa; people traveled to Zimbabwe from neighboring countries for complicated procedures, including pediatric heart surgery. One British-trained Zimbabwean doctor still working at Parirenyatwa took poloff on an unauthorized tour of the hospital and adjacent medical school facilities in September. At that time, the hospital still had some patients, but staff complained that the facilities had been badly neglected for years. While this deterioration has occurred across all health facilities for many years, in recent months the Zimbabwean government has proven unable to maintain stocks of even basic supplies such as bandages, gloves, medications, test tubes and reagents to run simple tests, and x-ray film. Mr. Thomas Zigora, CEO of Parirenyatwa Hospital, explained HARARE 00001039 002 OF 015 that hyperinflation and minimal budgets have left him unable to repair infrastructure and medical equipment. Whereas in years past hospitals could reasonably plan expenditures with their annual budgets, hyperinflation now strips their budget of meaning so quickly that hospitals no longer have any real operational funds. Compounding the budgetary woes, vendors increasingly demand foreign currency for everything from laundry soap to surgical tools. In addition, hospital staff - including doctors, nurses, cleaning crews, cooks, and other support personnel - cannot afford transport fees to come to work, as inflation has overtaken their meager salaries. While emigration has steadily eroded staffing in Zimbabwean medical facilities over recent years, in the last few months the absentee rate in medical facilities has been on the rise, magnifying the problem. In nursing, especially, hospitals are operating with minimum staff. Parirenyatwa, for example, should have 88 midwives but now has just 12; even these 12, however, are generally no longer reporting for duty. The GOZ has attempted to compensate for these shortages over the years by bringing in foreign doctors, including Cubans and Congolese, but these efforts have not resolved the staffing crisis. Many doctors now say that after years of steady decline, the health system has finally collapsed. ¶4. (SBU) Around October 24, staff at Harare Central Hospital, Parirenyatwa Hospital, and Chitungwiza Hospital discharged all patients that "could receive adequate care at home" and stopped coming to work in support of an unofficial strike. Before the stay-away, Harare Central Hospital had about 700 patients; as of November 18, only about 40 remain. Doctors insisted that the reason for the strike was not just their inadequate wages (less than USD 2 in September - for a surgeon),but also their inability to provide effective care to patients. Dr. Douglas Gwatidzo, the head of Zimbabwe Association of Doctors for Human Rights, told us that since August doctors have become increasingly vocal in their complaints to administrators and the Ministry of Health that the health system had deteriorated to a point where doctors could no longer work. Without adequate supplies or infrastructure, doctors were often left to watch patients die. These doctors and nurses decided to walk away, telling administrators that if the government wanted to believe hospitals were functioning, they could figure out a way to care for the patients themselves. Doctors familiar with the hospitals told us that Harare Central Hospital discharged all of its chronic psychiatric patients (30-50),and that in the children's ward only two abandoned children remain, including one with cerebral palsy. Some nurses have returned to check on the children and the handful of others, but they are largely unattended. The result of the "strike" and lack of supplies has been catastrophic, as hospitals can no longer provide medical care, forcing Zimbabweans to search for alternatives: private care, rural hospitals, or no care at all. The very wealthy fly to South Africa for care, a possibility for only a tiny group of elites. Unfortunately, Dr. Gwatidzo and other doctors tell us, most patients simply go home and hope for the best. -------------- -------------- Operation of Hope Shocked by Harare Central Hospital -------------- -------------- HARARE 00001039 003 OF 015 ¶5. (SBU) Operation of Hope, a team of philanthropic American doctors and nurses, arrived in Zimbabwe on October 31 with the intention of performing about 85 free cleft lip and cleft palate surgeries at Harare Central Hospital during a two week visit. The team has come every six months for the last couple of years, and this was their fourth visit to Zimbabwe. Despite warnings that the hospital infrastructure had crumbled since their last visit in May, they were shocked by what they saw. During their last visit the hospital was bustling and "normal"; this time, in contrast, it was empty and the only health professionals to be found were student nurses who live on-site and come to work just often enough to avoid losing their free housing. ¶6. (SBU) Some of Harare Central's dedicated nurses crossed the unofficial picket line to work with Operation of Hope, and the American staff noted they were significantly more demoralized than ever before. The Zimbabwean nurses told the Americans they knew Operation of Hope was coming because the hospital turned the water on. Operation of Hope only stayed at Harare Central for one week because they were unable to work. Jennifer Trubenbach, the executive director of the Washington-state-based charity, said that during their time at Harare Central they only performed 16 surgeries. They spent most of the time negotiating with administrators, who were under pressure to address other pressing issues to provide care for all patients. Hospital staff were discouraged that the American team would only perform the cleft lip and palate surgeries, which the Zimbabwean staff consider cosmetic, while other patients with critical care needs went untreated. While they were at Harare Central, the Operation of Hope surgeons were often the only doctors in the entire building. On at least three occasions they signed death certificates for Zimbabweans who brought in their recently deceased loved ones for the certificates that are a legal requirement for burial. ¶7. (SBU) The team left Harare Central on November 11 and spent its last four days at the privately funded St. Anne's Hospital, where they found significantly more motivated nurses and better infrastructure. When the team returns in May 2009 for another round of surgeries, it will go directly to St. Anne's. By the time the team left, it was only able to perform 42 surgeries, mostly because of the time lost working through the delicate logistics at the public hospital. -------------- Public Hospitals and Clinics All Struggle -------------- ¶8. (SBU) There is almost no end to the frightening anecdotes of inadequate medical care and crumbling infrastructure across Zimbabwe. Member of Parliament Thabitha Khumalo from Bulawayo East witnessed nurses using their cell phones as lights to deliver a baby and stitch up the mother. Doctors at the district hospital in Chivu are now adept in performing cesarean sections without any electronic monitoring, as they are without power about 20 hours per day. The two major referral hospitals in Mashonaland West, in Chinhoyi and HARARE 00001039 004 OF 015 Karoi, have functionally closed, citing water shortages. Ominously, cholera has been reported in both cities within the last two weeks. For many months, medical waste has only been incinerated sporadically at Harare's hospitals because of a lack of coal to fire up the incinerators. ¶9. (C) We spoke with Dr. Michael Simoyi, the medical director for the city of Chitungwiza, a populous high-density area near Harare. Dr. Simoyi obtained his master's degree at the University of Michigan and all four of his children are currently at universities in the U.S. He frankly told us of the serious woes facing Chitungwiza, where a cholera outbreak recently killed at least 17 people and afflicted 150. A 2002 census put Chitungwiza's population at 320,000; many estimate it is now home to about a million people. Residents rely for primary care on four public health clinics that are (normally) staffed by a total of 80 nurses on 24 hour shifts. Dr. Simoyi is the only physician and admits that high absentee rates mean that on any given day, each clinic is only staffed by about five nurses. Attempts to recruit another doctor have been unsuccessful. In the 1980s the government devoted significant attention to the primary health care system and purchased much of the equipment that the clinics still use. Now, however, the government simply doesn't care, he said. ¶10. (C) While the situation in Chitungwiza's clinics is bleak, they benefit significantly from donor funding because they are also a study site for USG-funded research grants through the University of California, San Francisco on mother-to-child-transmission of HIV and they are stocked with the associated supplies that accompany that funding. One doctor affiliated with the grant, local pediatrician Linda Stranix-Chibanda, runs a weekly well-baby clinic to provide assistance to the children of HIV-negative mothers who don't benefit from some of the donor-funded projects. She told us that at the end of October, she saw 16 babies, three of whom had kwashiorkor (protein deficiency),and three mothers with pellagra (niacin deficiency). Dr. Stranix-Chibanda, who has worked in Chitungwiza for years, said that while her sample was not scientific, she believed urban malnutrition was on the rise, even among those who historically had adequate resources and access to food. ¶11. (C) During the cholera outbreak, Dr. Simoyi relied heavily on donor-funded partners including Oxfam, Medecins Sans Frontiers, Red Cross, and UNICEF. They turned one of the clinics, Seke North, into a specialized center exclusively for cholera cases. However, Seke North, like clinics elsewhere in Zimbabwe, has no water. Dr. Simoyi told us that the problems of broken sewage pipes and constant water shortages continued six weeks later. Just outside the Chitungwiza municipal offices, adjacent to a high density neighborhood, we witnessed raw sewage running in the mud. None of the conditions that led to the initial outbreak have been addressed, and the current situation is a "ticking time bomb" according to Dr. Simoyi. Furthermore, the rains in Harare province only began this week and will significantly exacerbate the seasonal cholera rates as the rainy season continues. German Agro Action is now funding boreholes for clinics in Chitungwiza, which will at least provide the HARARE 00001039 005 OF 015 clinics with clean water. (NOTE: Oxfam and Agro Action are USAID-funded. END NOTE.) -------------- -------------- One Public Hospital Administrator ToQrty Line -------------- -------------- ¶12. (C) We also spoke with Mr. Obadiah Moyo, the CEO of Chitungwiza Hospital, whose overly rosy description of his hospital provided a glimpse at the political sensitivities of the health system. On October 28, Moyo - who asked us several times to keep his visit to the Embassy secret - told us that his hospital was still open and that while his stQ was tired, until mid-October, nearly 100 percent of staff at Chitungwiza Hospital were consistently coming to work. He further told us that his staff had successfully provided treatment to everyone that appeared at the hospital. ¶13. (SBU) However, a locally engaged staff (LES) member who lives in Chitungwiza painted a substantially different picture. She told us that a family friend's mother-in-law needed an x-ray to follow up on tuberculosis and was turned away. In addition, in late October the LES's daughter urgently needed an intravenous antibiotic and was turned away from both Chitungwiza and Parirenyatwa Hospitals before resorting to the expensive and private Avenues Clinic in Harare. Those with financil means have turned to private clinics while othrs have resorted to long bus rides to rural publc and church-sponsored mission hospitals for care. ¶14. (C) Mr. Moyo told us that drug supplies and infrastructure have declined in recent years, and foreign currency is needed to replenish stocks. In the meeting with donors and other CEOs on November 18, Mr. Moyo began his remarks by first explaining that the problem is a lack of cash because the RBZ cannot print enough, and he asked donors to support the hospitals and health infrastructure in a "big way". (NOTE: Moyo's business card indicates he has both a PhD and a medical degree. After our initial meeting, we learned that he earned neither. Rather, he was Sally Mugabe's dialysis technician at Parirenyatwa throughout her long struggle with a kidney disease. After Sally's death, Mr. Moyo suddenly became Dr. Moyo, and in 2004 he became CEO of Chitungwiza Hospital. END NOTE.) -------------- Private Hospitals Struggle Too -------------- ¶15. (SBU) We spoke with numerous doctors that work in both the public and private system, including Harare's two biggest private hospitals, St. Anne's Hospital and Avenues Clinic. Dr. Douglas Gwatidzo, director of the emergency room at the privately run Avenues Clinic (now the only functioning emergency room in the Harare area),told us on October 29 that the situation was "terrible." He described the health care collapse as the result of more than two decades of neglect by the government. Even in 1989 as a young doctor, he and others carried basic supplies like sutures between hospitals to compensate for sporadic supply shortages. Gwatidzo further blamed the decline in health care on HARARE 00001039 006 OF 015 ZANU-PF's inability to "figure out a way to make money from" the health sector. Even at Avenues Clinic, supply shortages are routine and, on the day we met, the Clinic did not have intravenous fluids, critical in stabilizing patients. Medical staff at Avenues Clinic are also underpaid, city water is inconsistent, and patients' families often have to visit private pharmacies to purchase basic supplies such as bandages, antiseptics, and drugs. ¶16. (C) St. Anne's Hospital, like Avenues Clinic, struggles to keep pace with rampant inflation and to maintain staff and supplies. St. Anne's Hospital administrator Munatsi Shumba told poloff that patients pay approximately USD 2-3,000 for a standard surgery, and that all payments must be made (usually in U.S. dollars) up front. St. Anne's Hospital primarily operates as a private surgical facility, with six operating theaters and 163 beds. Despite the functional closure of the public hospitals, neither St. Anne's nor Avenues Clinic has seen an increase in admitted patients, simply because prospective patients cannot afford private care. Despite the relatively large facility, Shumba said that only about 35 beds were occupied, half the number of a year ago. Since May, he said, Zimbabwean medical aid societies (medical insurance companies) had became worthless, meaning that now all patients must have access to enough cash to cover an entire hospital stay. ¶17. (SBU) Recently, an American citizen (ref) and an LES's adolescent daughter received inadequate care at Avenues Clinic, although it is still regarded as superior to St. Anne's Hospital. The LES, attending to her daughter after an operation, bathed her daughter every day (the nurses refused) and bought bandages in local pharmacies since they were unavailable in the hospital. In addition, the LES had to beg the nurses to change her surgical dressings. As with the Amcit, the teenage Zimbabwean girl had bed sores after just five days in the hospital because nurses did not turn her enough. ¶18. (C) Dr. Athan Dube, a urologist trained in the UK and the U.S. who has a private practice and directs the Urology Department at the University of Zimbabwe Medical School, told us that he usually sets aside five percent of his surgical charges to pay nurses extra to attend to his patients at both private and public (when open) hospitals. Dr. Dube also told us the quality of care a patient receives in a private facility depends almost entirely on the surgeon's attention to the patient. Harare's private hospitals do not have doctors on-staff in the wards, and both St. Anne's Hospital and Avenues Clinic rely on nurses to provide round-the-clock care. Increasingly, nurses are leaving the private health facilities for better opportunities outside Zimbabwe. Those who remain are less and less motivated to provide high-level care. -------------- -------------- Mission Hospitals Flooded With Harare Patients -------------- -------------- ¶19. (C) We visited Howard Hospital, about an hour north of Harare in Mashonaland West, on November 17. Howard is HARARE 00001039 007 OF 015 supported by the Salvation Army and is part of the Zimbabwe Association of Church-Related Hospitals (ZACH),which has about 125 hospitals across the country and provide approximately 65 percent of all rural health care in Zimbabwe. ZACH institutions are all officially part of the national health care system. The director, Canadian Dr. Paul Thistle, has worked at Howard Hospital since 1995 and is one of three doctors at the hospital. On a Monday morning, every ward in the hospital was already overflowing, and some patients were on mattresses on the floor. In 2007 Howard Hospital treated 140,000 patients, triple their historical population of 30-40,000 in the late 1990s. While Dr. Thistle has not yet tabulated statistics for 2008, he believes their patient load continued to increase during the year. Some of this increase is attributable to their large (USG-supported) HIV/AIDS clinic, but they have seen increases in patients demanding all kinds of services. Howard Hospital provides this additional care with the same staff they have counted on for many years - three doctors and 45 nurses - and increasingly limited resources. ¶20. (C) Even in the best of times, about 20 percent of Howard Hospital's clientele came from Harare (over an hour and a half away by public transportation),but now about half of Howard Hospital's patients come from Harare. Patients had been drawn to Howard because user fees were low and the wait time for elective surgeries was often months less than at Harare's public hospitals. Now, however, Thistle notices the increase in patients from Harare is mostly lower-middle and middle class patients who used to get care from public facilities in Harare. Only those with funds to afford the bus fee to Howard Hospital or who have a friend or relative with a car to transport them can access Howard. Because of the significant costs and delays in traveling from Harare to Howard Hospital, Dr. Thistle says many who arrive there are - often literally - on their "last gasp." Dr. Thistle repeated Dr. Gwatidzo's belief that Harare's poorest are likely dying at home. ¶21. (C) Howard Hospital relies heavily on private donations from NGOs and others. However, these programs are now struggling with hyperinflation and the growing crises of malnutrition, cholera, and infrastructure collapse. Howard Hospital is a site of a UNICEF-sponsored therapeutic feeding program for malnourished children. However, Howard Hospital has been without the "plumpy nut" peanut-based food that is vital to this program for about a month because they have not been able to coordinate a large enough truck to transport the food from Harare to the Hospital. Mothers bring their babies in for feeding and are told to come back in a week or two, hoping they will have received the food. UNICEF announced in a November 18 meeting that they are in "emergency" mode for at least a 120 day period. UNICEF is bringing in additional expert staff to help manage the organization's response to the growing humanitarian crisis. UNICEF has also ordered more trucks to ramp up its operations, which should improve food distribution. ¶22. (C) These narrowly targeted programs (e.g. therapeutic feeding, ARV provision, MTCT prevention) that used to supplement the government infrastructure now leave HARARE 00001039 008 OF 015 significant gaps as they usually do not cover basic, but vital supplies that the government now routinely fails to provide. For instance, Howard draws its water from a nearby reservoir, and must use expensive chemicals to treat the water. Last week they ran out of chlorine and had to boil water, when power was available. Cleaning supplies, soap, toilet paper, antibiotics, and other supplies are not provided by donors and are now only available with foreign currency. None of these supplies are attainable with the meager government budgets hospitals receive. Even Howard Hospital's phone has fallen victim; the copper wire has been stolen twice and now cannot be replaced, at least locally. With cholera case rates rising on a daily basis across the country and public hospitals closing, a lack of cleaning supplies and toilet papers at the best of Zimbabwe's rural medical facilities is ominous. ¶23. (C) Dr. Thistle likened his hospital to a "MASH unit," saying they are in constant crisis mode. On the surface, Howard Hospital looks like many rural African hospitals: crowded, chipped paint, but fortunate to have drugs and trained staff. However, as elsewhere in Zimbabwe the nurses at Howard Hospital are seriously underpaid and burned out. Last month their government salaries paid just Z$100,000 (about 10 cents at today's exchange rate). Howard Hospital uses its private funds to supplement staff salaries with privately-funded food packs that cost about USD 10 per month, but Dr. Thistle conceded the nurses often go hungry and struggle to feed their families. He attributed his staff's dedication in holding out to their commitment to caring for the patients who have nowhere else to go. However, as the political stalemate draws out and skepticism rises about a political solution, "everyone" is rethinking if they should stay or leave Zimbabwe. -------------- -------------- Emergency Facilities - Nearly Non-Existent -------------- -------------- ¶24. (SBU) Even before Parirenyatwa Hospital unofficially closed, its emergency room had become largely dysfunctional. A CNN report in October showed that the emergency room was staffed entirely by student nurses and no doctors were on duty. One LES attempted to take her ill daughter to the emergency room two consecutive days in September, but no doctors were on duty. In effect, Harare no longer has any public emergency facility. ¶25. (C) The only emergency room in Harare is now at Avenues Clinic where prospective patients must now pay cash up front- USD 140 - just to be seen by a doctor. An immediate cash payment of USD 1,000 is required for admittance at Avenues. Emergency Medical Rescue Ambulance Services (EMRAS),is one of two private ambulance services in Zimbabwe, with offices in Harare, Bulawayo, Gweru, Masvingo, and Mutare. EMRAS general manager Craig Turner told us that calls have dropped by more than half, since people know they cannot afford to pay for care at Avenues and no other care is available. At the height of their busy season in June, they received 25-30 calls per day. The day before we visited, EMRAS had received just three calls. He told us that taking patients to HARARE 00001039 009 OF 015 Parirenyatwa and Harare Central is a "waste of time" because even if the hospitals accept the patients, they are unable to treat them. EMRAS repeated Dr. Gwatidzo's supposition that people who would normally seek medical care are likely staying at home, becoming sicker, and dying. EMRAS now worries about its own bottom line. With the precipitous drop in calls and two of their senior staff leaving in October, it will be difficult for them to remain in the black through the end of 2008. ¶26. (C) Medical Air Rescue Service (MARS) is the other private ambulance service and also manages the only Zimbabwe-based air medical evacuation company. Zimbabweans who can afford to become members of MARS are guaranteed access to an ambulance and a flight to medically evacuate them to South Africa; it is the company the U.S. and other embassies use to ensure medical evacuation. MARS General Manager Shingi Chibvongodze explained their staffing, airplane, and ambulance availability to poloff, post medical officer, and conoff, after a recent complicated medical evacuation of an American citizen to Johannesburg. Like EMRAS, MARS relies largely on members and medical insurance subscribers for funding. However, MARS membership has more than halved from 1 million members to 400,000 in recent years. Chibvongodze told us that MARS is moving away from relying on medical insurance because it does not pay enough to them as a service provider, and private facilities demand cash on arrival. MARS estimates six of ten clients with medical insurance cannot afford the co-pay upon arrival at Avenues Clinic. When they are turned away from Avenues Clinic, MARS takes the patient to one of the public hospitals. Initially, Chibvongodze told us that MARS hadn't been turned away from a public hospital. After significant prodding, he admitted that adequate care is no longer available in the public health system, although sometimes MARS has no choice but to leave clients with whatever medical staff is available in the public hospital. During the course of our meeting it became increasingly clear that MARS is struggling to procure supplies including fuel for aircraft and ambulances. Chibvongodze told us that the government "raids" his office two to three times a month to "ensure MARS's licenses are up to date." (COMMENT: It appears that MARS considers their continued ability to keep fuel in their tanks and supplies in their ambulances a tremendous success. Given the current operating environment, it is a success. However, we are concerned about their ability to continue to provide a high level of service. END COMMENT.) -------------- Blood Availability Unpredictable -------------- ¶27. (C) On November 7, poloff and post medical officer visited the National Blood Service of Zimbabwe (NBSZ),a private facility that is the only source of blood in Zimbabwe. We were concerned about the availability of blood after an American citizen was unable to get blood for a needed transfusion (ref) and rumors of other similar incidents in recent weeks. Emmanuel Masvikeni, Public Relations Manager, explained that under ideal circumstances they should draw 80,000 units annually. In 2007, they only HARARE 00001039 010 OF 015 drew 52,000 units and failed to meet hospital requests by 22 percent. Despite these struggles, NBSZ maintains high standards and an extremely safe (0.33 percent of donors in 2007 were HIV positive, despite a national prevalence of 16 percent among adults),100 percent voluntary donor system. He told us that ideally, they should have 3,000 units on hand, and now they have about 2,000. Masvikeni explained that the NBSZ is unable to recoup its costs. First, it cannot charge hospitals more for each unit of blood (currently USD 70 per unit, or the equivalent in Zimbabwe dollars) without permission of the Ministry of Health and Child Welfare, which has refused to raise the price. Approximately 75 percent of blood is sold to government-run hospitals, which often don't pay or pay late when the Zimbabwe dollar equivalent has deteriorated. As a result, the NBSZ has operated at a severe financial deficit since ¶2006. The NBSZ, which was once a model within southern Africa, now relies heavily on foreign donors to help defray costs. ¶28. (C) The blood bank also faces the pervasive challenges of staffing and purchase of consumables. Nationally, it should have 40 nurses. Within the last year, 12 have left. Among its 18 nurses in Harare, five have left so far this year. This constant exodus of trained staff leaves a serious deficit as new staff are difficult to find and train. Masvikeni cited payment and retention of staff as the NBSZ's biggest challenge. ¶29. (C) In addition, purchase of consumables from office supplies to test tubes, blood bags, and reagents to test blood pose serious challenges. The blood bank relies heavily on USD 1.5 million from UNICEF's Expanded Support Program (ESP) to procure reagents to test blood for HIV, hepatitis, and other infectious diseases. Masvikeni gave us a tour of the blood bank and showed us a freezer full of donated blood that had not yet been tested. The freezer that should hold tested blood was completely empty, as the NBSZ had been out of buffer to test the blood for at least two weeks. According to the UNICEF procurement officer who works with the NBSZ, the ESP program provides test kits and blood bags, but not enough to fulfill all of the NBSZ's demands. Additional funding was expected in April, but had only become available in November. Consequently, the NBSZ has significantly reduced collection and testing has been delayed while waiting for the supplies to come through from South Africa. While the blood bank may have 2,000 units on hand, very few of those are ready for use. We have heard numerous cases in recent weeks of patients in public, private, and mission hospitals unsuccessfully requesting blood from the NBSZ. -------------- -------------- HIV/AIDS Clinics Have Drugs and Nurses -- Sometimes -------------- -------------- ¶30. (SBU) The doctors we spoke with all agree that the distribution of HIV/AIDS drugs is one of the only bright spots in the current health care crisis. We visited the district hospital in Chivu, about an hour south of Harare, in September and found it well stocked with ARVs and anti-TB HARARE 00001039 011 OF 015 drugs, but little else. Other hospitals and clinics tell the same tale. The international community's support for providing ARVs for Zimbabwe's large HIV-positive population and for the mother-to-child-transmission prevention program make these activities success stories. However, the closure of hospitals, increasing problems with distribution schemes, and absenteeism pose serious threats to these gains. ¶31. (SBU) Dr. Greg Powell, an Australian pediatrician who has practiced medicine in Zimbabwe since 1977, told us that Zimbabwe continues to have some of the highest ARV compliance rates in Africa. He credits Zimbabwe's strong history of paying attention to community health workers and primary care with the continued provision of health care in rural areas. Indeed, nurses at rural hospitals appear to have lower rates of absenteeism. Most live on the hospital grounds in free housing and have their own vegetable gardens on-site. Urban health workers struggle to pay for transportation and usually do not have enough land to support a large garden. ¶32. (C) Dr. Powell directs the J.F. Kapnek Trust, which administers two USAID-funded projects. The first involves prevention of mother-to-child-transmission of HIV/AIDS (PMTCT) in 26 districts that covered 100,000 mothers in 2007. The second supports Zimbabwe's growing population of over one million orphans and vulnerable children (OVC). Powell and other doctors that work with HIV programs told us that HIV-prevention and treatment programs are increasingly vulnerable to the systemic decline in both the health sector and the economy: absenteeism of nurses, closure of facilities, skyrocketing costs of drugs like antibiotics, and hunger. Despite NGO and donor efforts to ensure ARVs are available, the on-the-ground reality is that those systems are weakening. For instance, at Mount Selinda mission hospital in rural Manicaland ARVs are available, but the hospital is now devoid of nurses. In urban settings, over 4,000 patients who rely on Harare Central and Parirenyatwa hospitals for their supply of ARVs may or may not know that officials have made extraordinary efforts to ensure ARVs and nurses to administer them remain, despite widespread reports that the hospitals are closed. At a Chitungwiza clinic, one breastfeeding HIV-positive mother went to get her ARVs at the beginning of November, but was turned away because no one was there to give her the drugs. MPs from Manicaland told us about several clinics where one ARV has been unavailable for two months, because of distribution problems. We have also heard some rumors of people selling ARVs on the black market. Throughout the country, those who do not get enough to eat stop taking their ARVs. These disruptions to ARV compliance pose serious threats to Zimbabwe's success in battling the AIDS epidemic. -------------- Privately Funded HIV/AIDS Clinic Transformed Into Full-Service NGO -------------- ¶33. (C) Swiss Doctor Ruedi Luthy came to Zimbabwe in 2002, leaving behind a position as the director of infectious diseases at a Zurich hospital, to establish a clinic to use his first-world HIV/AIDS treatment background to benefit poor HARARE 00001039 012 OF 015 Zimbabweans who are HIV-positive. On November 11 we visited his clinic that now helps care for 1,900 patients, about one-third of whom are children, who meet strict inclusion criteria: people who are very poor, raising children, and have a job that is important to society (e.g. nurse, teacher, pastor). He describes his clinic as an orphan prevention program, as he seeks to provide care to key members of the community who can help provide for their families. While he initially planned to provide just ARVs and TB drugs, he has steadily ramped up services over the years to now include a full-service clinic, laboratory, and pharmacy, food and clothing distribution, and a preschool. Like Dr. Thistle at Howard Hospital, Dr. Luthy relies on a wide array of donors to obtain drugs and funding to pay his 14 nurses and two doctors and other operational costs. He reported that in recent weeks he had seen many children with severe diarrhea. He said that because public clinics lack laboratory resources, they will often simply prescribe an antibiotic and send the child away. He fears haphazard antibiotic use in the public sector will lead to increased drug resistance. -------------- No More Medical Insurance -------------- ¶34. (SBU) The collapse of medical insurance also affects our partners who implement U.S.-funded humanitarian aid programs. International NGOs including CARE and MercyCorps now tell us they can no longer provide medical coverage for their Zimbabwean staff and are struggling to cope. In one week, CARE spent USD 6,800 cash to cover medical expenses for three staff members who were desperately ill and did not have cash to obtain medical care on their own since their health insurance was not accepted at private facilities. With the closure of Parirenyatwa Hospital, the only dialysis facility in the country is one private clinic that no longer accepts medical insurance. Patients requiring two dialysis sessions per week are now forced to come up with about USD 400 per week. Dr. Gwatidzo told the press that "as a result of the hyperinflationary environment most medical aid insurance schemes have become meaningless and they have stopped covering any specialist care. If we go by what the general services withdrawal in state hospitals has been like, it's not surprising at all that the units were closed. Actually, it would have been a miracle if under this economic and political crisis these units had remained functional." -------------- GOZ Bureaucracy Pushes Up Drug Prices -------------- ¶35. (C) We spoke with Dr. Seku Naik, a Zimbabwean of Indian origin whose company works throughout SADC countries in pharmaceutical and medical supply production and distribution. In 2007 he finally moved his main office to South Africa, as stifling business conditions in Zimbabwe no longer allowed him to run regional operations out of Harare. Naik remains in Harare as the Zimbabwe representative; he is the largest distributor of pharmaceuticals to both public and private sectors. Ten years ago, he had 11 pharmacies across Zimbabwe, but he now has just three in Harare. Despite this HARARE 00001039 013 OF 015 decline, he still retains 10 percent of the national retail market. He has also learned to diversify his businesses. For instance, his pharmacy in the upmarket Sam Levy Village does about USD 15,000 per month, USD 10,000 of which is designer, imported perfume. He described the Medical Control Authority of Zimbabwe (MCZ) as the most expensive pharmaceutical registration system in the world. To register a new drug for use in Zimbabwe, he pays USD 2,100 for the initial registration and USD 600 annually to maintain the registration. Currently, Naik maintains these registrations for 200 drugs, a significant expenditure, which forces him to keep prices relatively high. He told us that Zimbabwe's requirements are the most stringent within the SADC region, and other SADC countries are slated to harmonize their requirements with Zimbabwe's in 2011. ¶36. (C) Zimbabwe's National Pharmacy (Natpharm) is a parastatal that acts as the primary distributor of drugs to institutions in the public sector. Dr. Naik told us that Natpharm has suffered from brain drain in recent years as NGOs have hired pharmacists to help with ARV and TB drug distribution. Dr. Naik also described a recent incident where donated TB drugs were nearly completely lost to expiration. He was contracted by the European Union to purchase 2.7 million euros worth of generic TB drugs that have a shelf life of just two years. The EU signed an agreement with the Ministry of Finance to coordinate the donation to the Ministry of Health, and the drugs were delivered to Natpharm for distribution, pending final signature of the agreement by the Ministry of Finance. According to Dr. Naik, the official at the Finance Ministry who was to sign the agreement suddenly went on leave and the document was not signed for many months. Dr. Naik believes the official may have been paid off because his competitors who had resourced name-brand drugs, rather than generics, were upset at having lost the contract. By the time Finance official signed the documents, the drugs only had a few months' validity remaining. -------------- Medical Profession in Peril -------------- ¶37. (C) Zimbabwe's medical school was once among the very best in Africa. On November 17, the medical school announced it was sending away all third, fourth, and fifth year students on vacation in light of the "situation in the teaching venues for clinical studies." Clinical training is normally conducted primarily at Harare's three main hospitals under the supervision of more senior doctors. In recent years, however, that training has been less and less supervised as absenteeism and brain drain pull senior doctors away from the public system. Numerous doctors told us that recent graduates are less confident, less qualified, have a weaker grasp on medical ethics, and - frighteningly - are often more arrogant. Dr. Powell told us that over 80 percent of Zimbabwean medical graduates now work overseas. In 2007, the Medical School was left with just 40 percent of its lecturers and an unprecedented 30 percent of students failed their final exams. Ten years ago, the pass rate was much higher. HARARE 00001039 014 OF 015 ¶38. (SBU) On November 18, over 700 doctors and nurses held a spirited but peaceful protest on the grounds of Parirenyatwa Hospital. They called for medicine in hospitals, clean water, fair pay, and for the government to end the cholera epidemic. About 70 riot police armed with batons and tear gas threatened them with arrest and prevented them from marching into town to the Ministry of Health. The medical professionals chanted "Zimbabwe has cholera" and declared "we know you won't beat us because you have sick mothers, too." After several hours, police chased the health workers and broke up the protest. Some demonstrators were beaten, but none seriously. No one was arrested. -------------- -------------- COMMENT: No Visible Light at the End of the Tunnel -------------- -------------- ¶39. (C) Zimbabwe's public health system from the rural health workers up to the complex surgeries at Parirenyatwa Hospital was once a model for Africa. The hospitals and clinics were clean and had reliable doctors, nurses, water, electricity, food, and medications. International donor programs for ARVs, maternal health, and other programs were welcomed additions to that strong government-provided infrastructure. Now, however, the foundation these programs once relied on has disappeared. Until the last few months, that downfall has been gradual, but now it has finally crashed. Nearly everyone we spoke with was emotional, most were angry, and some cried, when describing their frustration with the collapse and their inability to perform their profession. Given the collapse of the health system, we see several implications for the U.S. Mission in Zimbabwe. ¶40. (C) First, our health programs that support HIV/AIDS cannot achieve previous levels of success without strong health infrastructure. While we can and do successfully provide ARVs and TB drugs, clinics also need clean water, electricity, staff, and antibiotics to fight secondary infections and laboratories to test not only CD4 counts, but also to ensure AIDS patients are given the right drug to fight other illnesses they confront. Nurses and doctors need salaries they can survive on, and so do the kitchen, cleaning, and laundry staff. We are concerned about the lack of food and its negative impact on ARV compliance. If the government continues to neglect its duty to provide a basic health infrastructure, Zimbabwe's success in reducing its HIV prevalence could quickly be undone. While we have typically been reluctant to provide salary support, Zimbabwe is now in a full blown health care crisis, and this and other staff retention mechanisms are being carefully re-examined by the donor community. Several donors have come together to consider a comprehensive salary support program to improve retention across all hospitals and health institutions. This would ensure that staff at public, mission, and private institutions are paid comparably and would hopefully improve staff retention. However, even this support would not compensate for the continued inadequate infrastructure and supplies that medical professionals need to provide patient care. We continue to closely monitor access to critical HIV services and anti-retroviral treatment. HARARE 00001039 015 OF 015 ¶41. (C) Second, we need to closely monitor the health facilities that we depend on as a mission community. In the event of an emergency, we rely heavily on MARS for medical evacuation and Dr. Gwatidzo and Avenues Clinic to stabilize us. We are deeply troubled by their periodic lack of essential supplies like blood and intravenous fluids. (NOTE: While MARS might still be responsible for in-country transport, Post would likely rely on SOS International/Johannesburg for an air transfer to South Africa. END NOTE.) Our post medical officer and consular section are working with the regional medical officer to monitor the situation, increase the supplies available within the health unit, and examine how to best keep the mission and American citizen populations informed of what level of care they can realistically expect. END COMMENT. McGee