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In early April, Zimbabwe’s Vice-President and Health Minister, Dr. Constantino Chiwenga, indicated the state’s plan to introduce a law criminalizing the foreign recruitment of the country’s health workers.
“If one deliberately recruits and makes the country suffer, that is a crime against humanity. People are dying in hospitals because there are no nurses and doctors… Zimbabwe frowns at this heinous crime which is also a grave violation of human rights,” he said.
Chiwenga’s statement evoked strong responses from health workers. 4,000 health workers are estimated to have emigrated from Zimbabwe since February 2021.
Zimbabwe was one of 55 countries identified by the World Health Organization (WHO) in March to be facing the “most pressing health workforce challenges related to universal health coverage”—the density of doctors, nurses, and midwives being below the global median (49 per 10,000 people) and a universal health coverage service coverage index below a certain threshold (55).
In response to the report, the UK—one of the main countries receiving health workers from Zimbabwe—declared that it had placed the country on its Red List, stopping “all active recruitment” with immediate effect.
While health workers can still apply for employment in the UK on an independent, individual basis (as opposed to recruitment agencies), the process might become difficult amid reports that the Zimbabwean government has already stopped issuing verification letters that would clear people to work abroad.
Zimbabwe’s case illustrates longstanding issues regarding the impact of brain drain on poorer countries, especially in critical sectors such as health. 37 out of the 55 countries on the WHO’s list are in Africa, with the continent projected to face a shortage of 6.1 million health workers by 2030.
It also raises complex related questions regarding health workers’ rights and Global North-South inequality.
A public health system in collapse
“We have been facing challenges in the health sector for over two decades, these have now become perennial problems. Health workers are leaving the country to go to South Africa, Namibia, Botswana, but also to the UK, because of the poverty salaries that they are being given—A medical doctor is earning roughly around US$400 a month,” Dr. Norman Matara, secretary general of the Zimbabwe Association of Doctors for Human Rights (ZADHR), told Peoples Dispatch.
“Major hospitals, including the four central hospitals, are facing shortages of basic medications such as paracetamol. At the moment, there is not a single working radiotherapy machine in the country. Our biggest hospital has only one maternal operating theater, which was built before 1980. People are dying from things that are preventable.”
Just months before Zimbabwe recorded its first COVID-19 case in March 2020, the country was already seeing high rates of vacancy—34% for doctors and 64% for medical laboratory scientists.
For Matara, the root cause of the crisis lies in the lack of funding: “We are a signatory to the Abuja Declaration, where we committed to allocate 15% of our budget towards healthcare. However, we have not stuck to this commitment.”
However, for 2023, only 11% of the national budget has been allocated to the health and child care ministry.
Low pay and difficult working conditions in the sector have also prompted repeated protests and strikes by health workers, as wage increases as high as even 100% have failed to keep up with triple-digit inflation, which stood at 229.8% in January.
The rising cost of living and a local currency that has plunged in value have not only had a devastating impact on the value of real wages, but also on people’s access to healthcare—in a country where, according to Matara, only 8% of the population has health insurance, leaving the majority of people having to pay out-of-pocket to receive care.
The depreciation of the currency has also had implications for whatever funding the government is able to allot towards the health sector.
“The country’s central hospitals need about US$ 3 million each a year to function without shortages. However, in reality, they are getting only about 10% of the amount that is needed,” Matara said.
“The other issue is that the national currency is losing value almost on a daily basis, so even when the government does allocate money in the national budget, by the time it reaches hospitals, its value is a fifth or a tenth of what was allocated in the budget just four or five months ago.”
Meanwhile, as conditions have grown dire, the right of health workers to undertake industrial action to raise some of these issues has been severely curtailed under a new law that bans strikes by health workers for longer than three days. Workers or union leaders found defying these new conditions can be charged with a criminal offense and jailed for up to six months.
“This is an unconstitutional law which prevents health workers from practicing their guaranteed rights,” Matara says. Regarding the looming restrictions on foreign recruitment, he said, “this is another unconstitutional move. Section 66 of the Bill of Rights allows citizens to travel both within the country, and to leave the country, if they wish to do so.”
At the same time, he stressed that health workers would still prefer to remain and work in the country, at home and close to their families, if the conditions were permissible, and that rather than being pulled by foreign countries, health workers were being pushed out due to low pay and poor working conditions.
“If you address the conditions, no one will leave, and we will not have this crisis… We demand that the government prioritize the health sector, and to just meet the commitments made as part of the Abuja Declaration as a starting point.”
Realizing the Abuja Declaration’s vision
Signed at the African Summit on HIV/AIDS, Tuberculosis, and Other Related Infectious Diseases in the Nigerian capital of Abuja in 2001, this declaration was important beyond considerations of budgetary allocations when it comes to disease response, and broadly, health.
“We acknowledge that forced migrations due to war, conflicts, natural disasters and economic factors including unilateral sanctions imposed on some African countries, lead to an increased vulnerability and the spread of disease,” the text reads.
The declaration was issued just a month after the US started imposing illegal sanctions on Zimbabwe, first through the Zimbabwe Democracy and Economic Recovery Act (ZIDERA)—blocking the country’s access to funding from international financial institutions and to the cancellation or reduction of debts.
While the US continues to maintain that its sanctions do not target the Zimbabwean people, the country, or its banking sector, the reality is that these illegal measures have disrupted all aspects of life, including health, while isolating Zimbabwe from the international community. Despite its usual claims of wanting to uphold democracy and human rights, the US had imposed these sanctions to punish the Zimbabwean government for implementing a land reform program.
Following a trip to the country in 2021 to assess the negative impact of the sanctions on human rights, UN Special Rapporteur Alena Douhan noted that “health services remained poor amid a deteriorating infrastructure, a lack of funding, and shortages of all types of health care necessities,” as well as vacancy rates of over 50% among health staff.
In a written submission a year prior, the SADC Permanent Missions in Geneva had stated that Zimbabwe lost over US$42 billion in revenue over 19 years and had seen a GDP reduction of US$21 billion. “The significant progress that Zimbabwe had made in the development of infrastructure, as well as health, education, and other social service delivery systems has been severely reversed.”
Not only has Zimbabwe been cut off from an estimated US$100 billion in bilateral donor support, international commercial loans, and grants and loans from multilateral institutions, the government has also implemented policies of austerity—leading to low wages particularly in dominant sectors of the civil service including health and education—at the behest of these very institutions, including the International Monetary Fund (IMF), whose advice to the Zimbabwean government has consistently been to reduce the wage bill and lower employment costs.
While countries such as Zimbabwe are forced to implement policies that push down wages in critical sectors such as health, richer countries of the Global North are able to draw from an increasing pool of workers, even as workers in their own national health systems fight for basic rights and a living wage.
The impact of these austerity reforms is something that the WHO has still not adequately recognized, the People’s Health Movement has highlighted.
Austerity and related issues of debt remain integral to understanding the public health crises in countries of the Global South, as was acknowledged by the Abuja Declaration, which called for continued discussions with debt creditors “with the view to securing the total cancellation of Africa’s external debt in favor of increased investment in the social sector.”
Addressing the challenges of brain drain and health workforce shortages thus requires a much broader approach, one that respects the rights of health workers—to unionize and organize industrial action, to be paid a living wage, have access to proper infrastructure and equipment, and even have freedom of movement without any criminalization—while also addressing the factors that undermine ability of governments in these countries to promote development.
