Zimbabwe’s once proud achievements in health have been undermined over the past 20 years by increasing poverty, bad governance, poor economic policies, widespread HIV/AIDS, and a weakened health system. A Viewpoint published Online First and an upcoming edition of The Lancet states the priorities that the country must address to improve its currently horrendous health indicators. The Viewpoint is written by group of doctors with expert knowledge of Zimbabwe, led by Dr Charles Todd, former chairman, University of Zimbabwe School of Medicine, and Westongrove Partnership, Wendover Health Centre, Aylesbury, UK, and colleagues.

Zimbabwe’s Government of National Unity (GNU), established on Feb 13, 2009, has instigated at 100-day recovery plan, which has seen the country’s health sector gradually begin operating again, with doctors and nurses returning to posts and health centres once again operational. The decline in health indicators over the past three decades has been immense. Between 1990 and 2006, life expectancy at birth plummeted from 62 to 43 years, mostly from increased young adult mortality from HIV-related conditions. Mortality rates of children younger than 5 years and infants rose from 77 and 53 per 1000 livebirths in 1992 to 82 and 60 in 2003, respectively. Maternal mortality rose from 168 per 100 000 births in 199014 to 725 per 100 000 in 2007. Tuberculosis incidence increased from 136 per 100 000 in 1990 to 557 per 100 000 in 2006.These indicators are related to the high prevalence of HIV/ AIDS, which was estimated at 26% in 2000 in adults aged 15-45 years but declined to 15•3% by 2007. In 1994, 80•1% of children aged 12-23 months had received all basic vaccines compared with 74•8% in 1999 and only 52•6% in 2006-07.By early 2009, hospitals in the country were hardly operating, with massive shortages of essential medicines and supplies. Although most hospitals are now functioning again, shortages are still commonplace and patients usually need to buy medicines, intravenous fluids, and other supplies.

The authors believe priority must now go to the re-establishment of essential
services such as effective emergency obstetric care in all districts. This challenge will mean refocusing the work of central and provincial hospitals to providing secondary
health care. Furthermore, they suggest the following priorities for restoring Zimbabwe’s health service and health training institutions:

- The Ministry of Health, together with leading civil society groups, UN agencies, and donors, should evaluate implementation of the 100-day action plan and craft a budgeted, medium-term health-care recovery plan including priority actions to tackle Zimbabwe’s major health issues.

- The Health Services Fund-originally established in the 1990s to retain user fees at local level and later used for increased donor support to district health services-should be resuscitated. This would provide directly accessible funds for district health teams to maintain effective health services.

- The training of specialist mid-level workers (ie, clinical officers and nurse anaesthetists) should be rapidly restored and expanded, taking the lead from Malawi and Mozambique where such workers perform key frontline health functions. The existing health workforce cannot meet Zimbabwe’s needs so any resistance to specialist mid-level workers from professional associations must be overcome.

- The return of health professionals to Zimbabwe should be encouraged, but without disadvantaging those who have remained.

- The Ministry of Health should continue to promote an inclusive and cooperative ethos. Voluntary organisations and missions should be further supported. Civil society organisations involved in health should be formally recognised, and their advocacy of human rights and monitoring of donor funds encouraged.

- The political will to tackle the deep-rooted culture of violence and impunity should be nurtured and translated into legislation, including the establishment of a Healing and Reconciliation Commission and permitting human rights’ organisations to run programmes for community-based mental health care of survivors of organised violence.

The authors conclude: “Success in the 1980s was built on widespread community mobilisation accompanying a protracted struggle for human rights. Since then, Zimbabweans have been systematically deprived of these rights, including the right to health. A new opportunity now exists to rebuild the health-care system; its success will be contingent on firmly re-establishing the principles of social justice, equity, and public participation.”

Link to viewpoint

Source
The Lancet

A retreat from international funding commitments for AIDS threatens to undermine the dramatic gains made in reducing AIDS-related illness and death in recent years, according to a new report released today by the international medical humanitarian organization Doctors Without Borders/Medecins Sans Frontières (MSF).

International support to combat HIV/AIDS is faltering, as reflected in significant shortfalls among two of the world’s main funding mechanisms for HIV/AIDS. The board of directors of the Global Fund, a key financer of AIDS programs in poor countries, is unable to respond to countries’ needs. The board will vote next week in Addis Ababa whether or not to suspend all new funding proposals in 2010. The US President’s Emergency Plan for Aids Relief (PEPFAR), the American government’s AIDS program, is capping funding for two more years. This means that new patients will be turned away for treatment.

Report: Punishing Success: Early Signs of a Retreat from Commitment to HIV Care and Treatment.

The MSF report highlights how expanding access to HIV treatment has not only saved the lives of people living with AIDS but has been central to reducing overall mortality in a number of high HIV burden countries in southern Africa in recent years.

In Malawi and South Africa, MSF observed significant decreases in overall mortality in areas with high antiretroviral therapy (ART) coverage. Increased treatment coverage has also had an impact on the burden of other diseases. For example, tuberculosis cases have been significantly reduced in Thyolo, Malawi and Western Cape Province, South Africa.

“After almost a decade of progress in rolling out AIDS treatment we have seen substantial improvements, both for patients and public health,” said Dr. Tido von Schoen-Angerer, director of MSF’s Access to Essential Medicines Campaign. “Recent funding cuts mean doctors and nurses are being forced to turn HIV patients away from clinics, as if we were back in the 1990s before treatment was available.”

“The Global Fund must not cover up the deficit caused by its funders,” said von Schoen-Angerer. “The proposed cancellation of the 2010 funding round and other measures to slow the pace of treatment scale-up are punishing the successes of the past years and preventing countries from saving more lives.”

PEPFAR has had a huge impact on increasing the number of people on AIDS care and treatment in poor countries since 2003, supporting more than two million people on treatment with a commitment to increase treatment to at least three million by 2013. But U.S. government HIV/AIDS funding has remained the same for 2009 and 2010 and early signs indicate there will be no increase in funds for 2011 either. The proportion of PEPFAR’s budged dedicated to treatment has actually decreased. Only a handful of countries will be able to increase the number of new patients at a pace similar to what PEPFAR has supported in the past.

In 2005, world leaders promised to support universal AIDS coverage by 2010, a promise that encouraged many African governments to launch ambitious treatment programs.

“What about the promise made to people with AIDS?” said Olesi Ellemani Pasulani, MSF clinical officer in Thyolo District Hospital in Malawi. “We gave them hope and life. We have to be there for them. We all knew from the beginning that this treatment was for life. Passing on the bill for treating AIDS to very poor countries would be a colossal betrayal.”

Reducing funding at this time will leave people in urgent need of treatment to die prematurely, and can lead to dangerous interruption of treatment.

In Uganda, cuts have already begun to hit home, with some facilities forced to stop treating new patients with HIV. Other countries are backing away from their earlier treatment coverage targets. In Free State, South Africa, past funding problems-since resolved-led to disruption of treatment and a moratorium on treating new patients, which resulted in an estimated 3,000 deaths.

The report provides evidence that treating AIDS, particularly in high prevalence settings, has a positive impact on other important health goals, in particular maternal and child health.

“A stronger commitment to other health priorities must happen, but this should be in addition to, not instead of, continued, increased commitment to HIV/AIDS,” said von Schoen-Angerer.

At present, over four million people living with HIV/AIDS in the developing world receive antiretroviral therapy. An estimated six million people who are in need of life-saving treatment are still waiting for access. MSF operates HIV/AIDS programs in approximately 30 countries and provides antiretroviral treatment to more than 140,000 HIV-positive adults and children.

Source
Doctors Without Borders/Medecins Sans Frontières