COLLAPSE: ZIMBABWE'S HEALTH CARE SYSTEM

C O N F I D E N T I A L SECTION 01 OF 15 HARARE 001039

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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).

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SUMMARY
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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.

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Harare's Public Hospitals: Officially Open,
but Functionally Closed
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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

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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.

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Operation of Hope Shocked by Harare Central Hospital
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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.

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Public Hospitals and Clinics All Struggle
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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

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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

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clinics with clean water. (NOTE: Oxfam and Agro Action are
USAID-funded. END NOTE.)

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One Public Hospital Administrator ToQrty Line
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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.)

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Private Hospitals Struggle Too
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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

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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.

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Mission Hospitals Flooded With Harare Patients
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19. (C) We visited Howard Hospital, about an hour north of
Harare in Mashonaland West, on November 17. Howard is

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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

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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.

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Emergency Facilities - Nearly Non-Existent
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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

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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.)

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Blood Availability Unpredictable
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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

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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

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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.

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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