A note about this series: Global Press Journal reporters around the world examined their communities’ approaches to reproductive health, including values and priorities and how international policies impact them. Read the other stories in this month-long series here.
CONCESSION, ZIMBABWE — Agnes Machengo’s face blossoms with joy as she holds her newborn baby boy at the hospital in this town about 58 kilometers (36 miles) north of the capital city of Harare .
Machengo, 21, had a successful delivery – and she doesn’t have to worry about the bill.
“I was admitted here without paying anything,” she says.
In late 2017, Zimbabwe’s president, Emmerson Mnangagwa, announced that all costs associated with maternity care at public hospitals would be covered by the government, as well as care for children under 5 years old and adults over 65.
But that’s not why Machengo doesn’t have a bill to pay. In fact, it wasn’t until recently that one hospital even received any money related to that new policy.
Free maternity care has been available in some rural areas of Zimbabwe since 2012 under a scheme called results-based financing (RBF). RBF reimburses the costs hospitals incur from providing free healthcare. Funding is tied to certain performance targets, such as the number of antenatal care or child growth monitoring visits carried out.
Gamuchirai Masiyiwa, GPJ Zimbabwe
RBF is part of a donor program called the Health Development Fund. It has been tied to the World Bank, and is now funded in Zimbabwe by Canada, Ireland, Norway, Sweden, the United Kingdom, the European Union and Gavi, the Vaccine Alliance. That funding allows for services to be provided in all of Zimbabwe’s 42 rural districts, covering 835 health facilities and 67 hospitals. About 6.6 million people are served in total, according to a 2018 report by Crown Agents, the company that delivers the program.
For Zimbabweans, who often struggle to make ends meet, the program makes a huge difference, Machengo says.
“Some people even fail to buy preparation clothes for their babies,” she says. “It’s obvious that such a person will not be able to pay maternity fees.”
But these benefits aren’t always available to mothers who give birth in Zimbabwe’s cities, where hospitals are scrambling to implement Mnangagwa’s 2017 policy without the government money needed to cover expenses.
“There is no support that has reimbursed the free services we have given,” says Nyasha Masuka, who until April was the Chief Executive Officer for Harare Central Hospital. Masuka spoke with GPJ while he was in that leadership role.
When Masuka first spoke with GPJ, he said the hospital had lost $3.5 million in bond notes ($636,364) on services for pregnant women alone, and about $6 million in bond notes (a little over $1 million) on all of the groups exempted from paying for services according to the policy. Since then, he says, the government has reimbursed the hospital to the amount of $3.2 million in bond notes ($581,818). But up until that point, hospital officials didn’t know how they would continue offering services.
Harare Central Hospital is not a general facility. It’s only supposed to cater to women with pregnancy complications who are referred there for specialist care. But Masuka says that changed since Mnangagwa’s policy was introduced. In September 2018, for example, the hospital cared for more than 500 walk-in patients who showed up because they knew they wouldn’t have to pay fees, he says.
Masuka says the hospital sometimes gets support from donors, including the World Bank, which helps provide delivery kits and other consumables for maternal healthcare. About a year ago, some funding received via the RBF program paid for deliveries and cesarean sections done for “poor and vulnerable women,” he says.
But as of March 2018, funding from the World Bank stopped and it wasn’t clear whether there would be any other money, from the Zimbabwean government or otherwise, to continue the program.
Now, Masuka says, pregnant women often have to buy their own medical supplies.
“The commodity supplies we have are not enough, given the number of women coming,” he says. “We end up giving prescriptions for them to go buy things for themselves.”
The hospital’s staff has also suffered, he says. Some midwives are suffering burn-out because staffing levels haven’t increased to match the uptick in the number of patients.
In the Mazowe district, where Machengo gave birth, RBF allows health facilities to focus on quality of service rather than quantity, says Dr. Isaac Nzvede, the district’s medical officer.
He says the hospital carries out between 130 and 165 normal deliveries per month, plus between eight and 15 cesarean sections.
But even in rural Zimbabwe, which benefits from the RBF program, the country’s volatile economy causes problems for hospitals. As of the end of 2018, the program’s funding was provided in either U.S. dollars or bond notes, the pseudo-currency distributed by the government, depending on the district.
A C-section costs between $200 and $400 in bond notes ($36 to $73) to perform, but the RBF program reimburses just $50 in bond notes ($9), Nzvede says.
“The mismatch is too much,” he says.
Masuka, the chief executive at Harare Central Hospital, says he’s supportive of Mnangagwa’s policy, even though it doesn’t always provide the requisite funding.
It’s not clear whether the government will step in again to make up for future shortfalls.
“I think policy-makers should formulate a policy, get a budget for it and [then] implement it using that budget,” he says. And while the hospital has covered some of its losses for the short-term, Masuka isn’t confident about the future.
“At this rate, there will come a time when Harare hospital will close because we are just living hand-to-mouth. There will come a time when there is no money,” he adds.
Gamuchirai Masiyiwa, GPJ, translated some interviews from Shona.