zimbabwe public expenditure notes challenges in financing...
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Report No. 3
ZIMBABWE
Public Expenditure Notes
Challenges in Financing Education, Health, and Social
Protection Expenditures in Zimbabwe
February 2, 2011
Poverty Reduction and Economic Management Unit
Africa Region
The preparation of Public Expenditure Notes has been partially financed by the Analytic
Multi-Donor Trust Fund, Zimbabwe.
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ABBREVIATIONS AND ACRONYMS
AIDS Acquired Immune Deficiency Syndrome
AMTO Assisted Medical Treatment Orders
ANC Antenatal Care
ARI Acute Respiratory Infection
ART Anti-Retroviral Therapy
BEAM Basic Education Assistance Module
CCT Conditional Cash Transfer
CSC Community Selection Committee
DfID United Kingdom Department for International Development
EPI Expanded Programme on Immunization
ETF Education Transition Fund
HIV Human Immunodeficiency Virus/
ICES Income, Consumption, and Expenditure Survey
IMF International Monetary Fund
MDGs Millennium Development Goals
MHTE Ministry of Higher and Tertiary Education
MIMS Multiple Indicator Monitoring Survey
MLSS Ministry of Labor and Social Services
MOESAC Ministry of Education, Sport and Culture
MOHCW Ministry of Health and Child Welfare
NatPharm National Pharmaceutical Company of Zimbabwe
NGO Non-Governmental Organization
OVC Orphan and Vulnerable Children
PASS Poverty Assessment Study Survey
PFMS Public Financial Management System
PPP Private-Public Partnership
PWP Public Works Program
SPEs Social Public Expenditures
TB Tuberculosis
TFR Total Fertility Rate
TTC Teacher Training College
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
UNICEF United Nations Children's Fund
USAID United States Agency for International Development
WHO World Health Organization
ZIMSEC Zimbabwe School Examination Council
ZIMSTAT Zimbabwe National Statistics Agency
Vice President:
Acting Country Director:
Sector Director:
Sector Manager:
Task Team Leader:
Obiageli Katryn Ezekwesili
Olivier Godron
Marcelo Giugale
John Panzer
Pablo Acosta
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ACKNOWLEDGMENTS
This policy note is one of the four of the Zimbabwe Public Expenditure Notes, prepared by
the Poverty Reduction and Economic Management and Human Development Units of the
Africa Region of the World Bank, with financing from the Analytical Multi-Donor Trust
Fund.
This note was prepared by Pablo Acosta (Economist, Task Team Leader), with inputs from
Susan Hirshberg (Senior Education Specialist), Anush Bezhanyan (Lead Social Protection
Specialist), Monique Vledder (Senior Health Specialist), Mirja Sjoblom (Operations Officer),
Ronald Mutasa (Extended Term Consultant), Ruth Wutete (Extended Term Consultant),
Mario Gutierrez (Consultant), Jean-Pierre Manshande (Consultant), Dominic Muntanga
(Consultant), and Rafael Novella (Consultant). The work was guided by Praveen Kumar
(Lead Economist) and supervised by John Panzer (Sector Manager) and Nginya Mungai
Lenneiye (Country Manager).
The team would like to express its gratitude to authorities of the Government of Zimbabwe
for their guidance and close cooperation (including authorities at the Ministry of Finance, the
Ministry of Education, Sports, Arts, and Culture, the Ministry of Higher and Tertiary
Education, the Ministry of Health and Child Welfare, and the Ministry of Labor and Social
Services).
The team also benefitted significantly from the advice and substantive inputs of colleagues in
the Bank including Peter Nicholas (Lead Operations Officer), and Tendeukayi Mugadza
(Economist). We are also very grateful to Aline Coudouel (Senior Economist) and Gary Reid
(Lead Public Sector Specialist), who kindly peer reviewed and provided comments to this
note, as well as colleagues from development partners and members of the Economic
Technical Review Group in Zimbabwe (including UNDP, UNICEF, DfID, USAID, the
European Union, and the African Development Bank). The administrative assistance for this
task was provided by Priscilla Mutikani from the Zimbabwe Country Office, and Sara
Sundaram and Dotilda Sidibe at World Bank headquarters in Washington, DC.
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CONTENTS
Executive Summary ..................................................................................................................... 6 I. Introduction ............................................................................................................................ 15 II. Recent Trends in Social Expenditures ................................................................................. 18 III. Challenges in the Education Sector .................................................................................... 33 IV. Challenges in the Health Sector .......................................................................................... 45 V. Challenges in the Social Protection Sector .......................................................................... 59 VI. Policy Recommendations ..................................................................................................... 67 References ................................................................................................................................... 77
Tables Table 1: Selected Macroeconomic Indicators, 2000–10 ........................................................... 15 Table 2: Selected Social Indicators, 1990–2009 ........................................................................ 17 Table 3: Expenditures in Basic Education (Percent of 2011 Sector Budget) ......................... 24 Table 4: Expenditures in Higher Education (Percent of 2011 Sector Budget) ...................... 27 Table 5: Expenditures in Health (Percent of 2011 Sector Budget) ......................................... 28 Table 6: Expected Donor Assistance in Health, 2010 (US$ millions) ...................................... 30 Table 7: Expenditures in Social Protection (Percent of 2011 Sector Budget) ........................ 31 Table 8: Expected Donor Assistance in Social Protection and Food Security, 2010 ............. 33 Table 9: National Grade 7 Pass Rates for Primary School, 2006–09 ...................................... 41 Table 10: Total Enrollment in Teachers Training Colleges, 2007–09 .................................... 42 Table 11: Total Enrollment in Universities, 2007–09 ............................................................... 43 Table 12: Total Enrollment in Polytechnics, 2007–09 .............................................................. 43 Table 13: Graduation Rates in Higher and Tertiary Institutions, 2007–09 ........................... 44 Table 14: Progress Toward Selected Health-related MDGs ................................................... 46 Table 15: Registered Facilities (Including Mission Hospitals) Managed by the Ministry of
Health and Child Welfare, 2006 ................................................................................................. 55 Table 16: Government-Funded Social Protection Interventions, 2010 .................................. 64 Table 17: Suggested Short-Term Budget Allocations for Social Sectors, 2012 and 2013 (millions
of US$) .......................................................................................................................................... 67
Figures Figure 1: Social Public Expenditures, 2005, 2009, 2010, and 2011 ......................................... 19 Figure 2: Social Public Expenditures by Sector, 2000–11 ....................................................... 19 Figure 3: Social Public Expenditures, 2000–11......................................................................... 20 Figure 4: Expenditure per Student, Basic Education, Zimbabwe, 2011, and Sub-Saharan
Africa, Average 2005–08 ............................................................................................................. 23 Figure 5: Public Spending on Basic Education (Percent of GDP), Zimbabwe, 2011, and Sub-
Saharan Countries, Average 2003–08 ........................................................................................ 23 Figure 6: Public Expenditure in Health (Percent of GDP), Zimbabwe, 2011, and Sub-Saharan
Countries, Average 2003–08 ....................................................................................................... 28 Figure 7: Per Capita Public Expenditure on Health, Zimbabwe, 2011, and Sub-Saharan Africa,
Average 2005–07 .......................................................................................................................... 28 Figure 8: Educational Level of Adults (22–65 years old), 2001–07 ......................................... 34 Figure 9: Primary and Secondary School Enrollment, 2002–09 ............................................. 35 Figure 10: Primary Enrollment by Grade and Year, 2006–09 ................................................ 36
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Figure 11: Secondary Enrollment by Form and Year, 2006–09 ............................................. 36 Figure 12: Primary Enrollment in Private Education, 2001–07 ............................................. 38 Figure 13: Figure Pupil-to-Teacher Ratio in Primary Education, Sub-Saharan Africa, Average
2004–09 ......................................................................................................................................... 39 Figure 14: Pupil-to-Teacher Ratio in Secondary Education, Sub-Saharan Africa. Average 2004–
09 ................................................................................................................................................... 40 Figure 15: Percentage of Female Students Enrolled at the Tertiary Level, 2007–09 ............ 44 Figure 16: Life Expectancy at Birth and GDP per Capita (constant 2000 US$) ................... 45 Figure 17: Trends in Infant and Under-Five Mortality Indicators ........................................ 47 Figure 18: Principal Causes of In-Patient Mortality at the Hospital Level (excluding Central
Hospitals) for Children under Five in 2006 (Number of Deaths) ............................................ 47 Figure 19: Diarrhea Prevalence for Children under Five ....................................................... 48 Figure 20: Nutritional Status of Children, 1994–2008 ............................................................. 49 Figure 21: Main Causes of Maternal Mortality, 2007 .............................................................. 51 Figure 22: Projections for Total Fertility Rate (TFR) and Population Growth .................... 51 Figure 23: Malaria Incidence Rates per 1,000 Population ...................................................... 53 Figure 24: Vacancy Rates (Percentage of Established Positions) at Government Health Care-
Related Institutions ..................................................................................................................... 56 Figure 25: Evolution of Beneficiaries of Public Works Programs, 2004–08 .......................... 60 Figure 26: Employment Categories, 2007–08 ........................................................................... 62 Figure 27: BEAM Beneficiaries in Primary School, 2001–10 ................................................. 63 Figure 28: Percentage of Households Receiving Cash Remittances by Province, 2007–08 .. 66
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Executive Summary
Overview
1. Zimbabwe’s economic conditions sharply deteriorated from 2000 to 2008,
severely impacting social well-being. During this period, Zimbabwe experienced political
crises accompanied by economic decline. GDP fell by more than 40 percent between 2000
and 2008, and hyperinflation peaked in September 2008 at about 500 billion percent, before
the Zimbabwe Dollar went out of circulation. The current estimated GDP per capita of $432
places Zimbabwe as one of the poorest countries in the world. More than half the population
is submerged in poverty. While recent official poverty figures are not available, poverty is
likely to be much higher than the latest available data (from 2003), when 53 percent of the
urban population and 63 percent of the rural population was living below the food poverty
line.
2. The crisis also decimated fiscal resources of the government, and thus
compromised social service delivery. Prior to the hyperinflationary period, in 2005, the
Government of Zimbabwe used to spend more than 15 percent of GDP on social
expenditures. The economic collapse and hyperinflation left social sectors with limited
funding from public sources, and by 2009 social public expenditures accounted for only 6
percent of GDP, with budgets for education and health cut by more than half, compared to
2005. With funding at minimum levels, by the end of 2008 most schools and many hospitals
closed, and transport and electricity networks were severely compromised.
3. The human cost of the economic, political, and fiscal crisis has been catastrophic,
as reflected in a number of social indicators. Life expectancy at birth dramatically declined
in the 2000s, while infant, child, and maternal mortality rose in the same period. Near a
quarter of children are orphans, most of them cared for by elderly who do not have access to
pension payments or other forms of public social transfer payments. While school enrollment
rates still being high by African standards, many children are dropping out of school since
their families cannot afford the required school fees. Doctors and teachers’ retention, in
particular in rural areas, has been difficult due to low salaries and brain drain to neighboring
countries. At this pace, Zimbabwe is not likely to achieve the Millennium Development
Goals (MDGs) by 2015, in particular those related to achieving universal primary education,
access to reproductive health, and access to treatment for HIV/AIDS, as well as reductions by
two-thirds in infant mortality, and by three-quarters in maternal mortality.
4. The situation has improved somewhat since 2009, with the recovery in collection
of revenues and allocation of additional resources to social sectors. With macroeconomic
stabilization, the economy grew again in 2009, and consequently tax collections also
rebounded. But the public sector still faces hard choices to meet competing demands within a
severely constrained budget. Social sectors are receiving more public resources than before;
in 2010, budgeted resources to social sectors reached 11.6 percent of GDP, almost twice as
much as in 2009. For 2011, the government has recently announced that resources to the
social sector will reach 16 percent of GDP, back to the level in 2005.
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5. The recent increase in allocation to social sectors is welcome but service delivery
levels are still far from historical levels. The increased funding is primarily going to pay
salaries, with low amounts directed toward other critical expenditures, such as books in the
education sector, or medicine in the health sector. Users are being asked to contribute
significantly to direct out-of pocket payments for services. Donor financing continues to be
critical to ensure continuity in the provision of essential services. Several challenges lie
ahead in social sectors that will require revisiting the adequacy and impact of social spending
to achieve meaningful progress. For instance, Zimbabwe’s health system, which after
achievements in the 1980s was referred to as the leading example in Africa, is now
characterized by a deficit of medical and managerial health professionals, severe shortages of
essential drugs and medical supplies, inadequate provision and maintenance of equipment
and infrastructure, and dilapidated transportation and telecommunications systems, especially
at the primary care level in rural areas. Similarly, the education system, which until the 1990s
was widely seen as one of the strongest in Africa, is today in a crisis that is reflected in
insufficient learning materials, dilapidated school infrastructure, and low credibility of the
national examination system. The human resource situation in these sectors is particularly
serious, since many qualified doctors, nurses, and teachers have left the country, given
current salaries. The government-financed social protection program is currently inadequate
to cushion the increasing numbers of poor and vulnerable groups (orphans, disabled, elderly),
except the Basic Education Assistance Module (BEAM), which too suffers from chronic
underfunding. Unless these factors are tackled, they will have a long-term impact on the
development of human capital.
6. Importantly, the government still lacks an explicit medium-term reform agenda
that would help prioritize public expenditure within each of the social sectors. There is
room to reallocate resources within social sectors, particularly to nonwage expenditures. For
example, alternative private funding sources for higher education (user fees) could be
explored to liberate resources for primary and secondary schools, particularly for school
material and infrastructure. In health it would produce greater overall health benefits if
primary health care in district and rural regions is given priority, over urban central hospitals,
unlike the current practice. However, there is absence of explicit statement of sector goals
and objectives and programs, and interventions that would support such goals and objectives,
to inform prioritization. Today, with the exception of health, which recently produced its
comprehensive medium-term strategy with donor support, budget proposals from social
sector ministries appear not to be directly linked to major objectives and indicators of
medium-term strategy. Line ministries have low capacity to contribute to the planning
process and identify priorities to finance with the scarce available resources. As with the rest
of the public administration, the Public Finance Management System (PFMS) in social
sectors is still experiencing severe implementation challenges.
General Policy Recommendations for Social Sectors
7. Subject to efficient utilization of increased level of funding to the social sectors,
there would be scope to allocate more resources to social sectors in the medium-term.
The Government of Zimbabwe is still, for most part, operating in an emergency environment.
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But with macroeconomic and fiscal stability consolidation, it is important to put in place a
coherent set of policies and investments to ensure that the Zimbabwean population,
particularly the poor, can benefit from social service delivery. Despite the well-know fiscal
challenges, there is room to reallocate resources to key priority social sectors. This is
essential to allow a steady recovery of coverage and quality of service delivery. Despite the
increase in 2011, Zimbabwe will fall short of its past and regional trends in social sector
spending and performance. Indicatively, allocation to social sectors could go up to 18.5
percent of GDP in the medium-term. Table A proposes an indicative breakup of such an
allocation across the three sectors.
Table A. Suggested Short-Term Budget Allocations for Social Sectors, 2012 and 2013
(millions of US$) Area 2010 2011 2012 2013
Basic Education 292.2 469.0 564.1 620.6
Higher Education 116.0 157.0 165.9 182.5
Health 157.1 257.0 365.0 401.5
Social Protection 52.1 80.0 132.7 146.0
Total 617.4 963.0 1,227.8 1,350.6
% of Budget ** 35.3 35.0 40.6 40.6
% of GDP*** 11.6 16.0 18.5 18.5
** Assuming a growth in the budget envelope of 10% in 2012 and 2013.*** Assuming a real GDP growth and inflation of 5% each in 2012 and 2013.
* Includes Ministry of Labor and Social Services; Ministry of Women's Affairs, Gender and Community
Development; and Ministry of Youth, Indigenization and Empowerment.
8. It would also be essential to develop medium-term strategies to recover service
delivery in all social sectors. This should include better prioritization across goals and
objectives. Due to the prevailing circumstances, any prioritization is bound to be short-term
and ad hoc, but eventually it is desirable to have a longer-term strategic plan to guide the
budgeting process. Ideally, when planning and implementation capacity has improved, a
results-based framework with specific goals, milestones, and outcome indicators should
orient budget formulation. The government has started to do that with the 2011 Budget
formulation, although effective implementation is probably too ambitious in the short term. It
would also require strengthening reporting and control of what is being accomplished with
budget resources. Prioritization is just part of the equation; several procurement and
implementation challenges are emerging given the lack of expertise in the government after
years of skill flight. It is critical to train staff in line ministries and the Ministry of Finance on
modern budgeting techniques and financial management.
9. Social sector line ministries and the Ministry of Finance need to have more say
in managing human resources in the sectors. Employment costs are consuming most of the
resources allocated to social sectors. While constraints in human resource areas for health are
enormous, in education there is room for rationalization (in particular in secondary
education) and for introducing alternative payment schemes. Though challenging and
debatable even in member-countries of the Organization for Economic Co-operation and
Development (OECD), the government could consider piloting performance-based payment
schemes in sectors such as health, to test their viability over the medium term to retain high-
qualified staff in the public sector. Aside from extra compensation, other examples of
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effective incentives to retain essential personnel in the disadvantaged areas include career
rotation requirements, business process reengineering, and contracting out or privatizing
services.
10. Targeting of social sector interventions should be strengthened through
transparent mechanisms that promote greater accountability. Current targeting of social
sector interventions is based on outdated pre-crisis data. It is critical to collect updated
information on poverty and vulnerability indicators to help policy makers in Zimbabwe
identify priority geographic and demographic areas of interventions, and create a unified
targeting mechanism. Within communities, either self-selection (for public works programs)
or community-level targeting (for BEAM, or health assistance) could be a better way to
create social cohesion and transparency in the selection of beneficiaries. Stricter adherence to
guidelines and verification of selected candidates are critical to achieve intended results.
Furthermore, a centralized beneficiary database is recommended to effectively track targeted
groups and avoid program overlaps and inefficiencies.
11. While difficult in the short-term, or even in the medium-term, Zimbabwe should
progressively embark on a path toward abolishing user fees, and finance them through
general taxation. User fees are an inefficient, regressive, and unfair way to cover funding
gaps in basic social sectors, since the most needed segments of the population get excluded
from access to these services. With economic and fiscal recovery, the government could take
a stand and reduce fee for services, either across the board or through subsidies to targeted
segments of the population. User fees could be phased out in steps, first focused on
abolishing the fees for the highest priority interventions (as primary education, or core
maternal and child health services). Demand-side interventions, like conditional cash
transfers (CCTs) that provide cash in exchange of beneficiaries attending school and health
centers for regular check-ups, can be a cost-effective way to target and reduce financial
barriers to access even while user fees continue to be in place.
12. The private sector and local communities also have the potential to contribute
meaningfully to the process of achieving social sector objectives. This potential needs to
be tapped and coordinated. Though cooperation between the private and public sectors has
existed for a long time, this has been ad hoc and informal. Opportunities could be explored to
increase the capacity of local manufacturers, to produce essential supplies for the education
and health sector (such as textbooks, drugs, equipment): a challenge in the case of health
given that no drug manufacturer operating in Zimbabwe is prequalified by the World Health
Organization (WHO). Introduction of a comprehensive private-public partnerships (PPPs)
scheme in the health and education sectors could also lead to improved working conditions
and thus attract skilled personnel back to the sectors. Communities could play a greater role
in the management of facilities and services, and also in rebuilding infrastructure.
Community infrastructure initiatives could help better identify local priorities and create
employment opportunities in the area.
13. The government also needs to increase its role in guiding and coordinating
donor interventions. Donors have played a major role in financing social expenditures even
prior to the economic crisis, and increasingly after that. Improved government-donor
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coordination is essential to ensure support to critical social service delivery while preventing
unnecessary duplication of efforts. The government should also continue to mobilize non-
governmental organizations (NGOs) and agencies to take up its role in service provision until
it is capable of resuming these tasks with own resources.
Sector-specific Recommendations
Education
14. Additional public resources to basic education may need to be considered over
the medium term. Primary and secondary education share in budget, at 17 percent, has
fallen below historical rates of 25 percent in 2000–05 and below what is required for efficient
delivery of educational services and achieving desired outcomes. On a per capita basis, it
would be advisable to raise public financing of the sector from the current US$115 and
US$200 per student in primary and secondary education respectively, to at least US$140 and
US$255 respectively. Over the medium term, public funding for basic education should be
raised progressively to account at least 8.5 percent of GDP, up from the current 7.8 percent.
These additional resources should prioritize nonwage recurrent expenditures (such as
teaching materials, school grants, supervision, and information systems) and some capital
expenditures (mostly on water and sanitation in schools), and avoid further increases in
payroll costs.
15. A further increase in the basic education budget could be achieved by
reallocation from higher education. Public funding of tertiary education is usually
inequitable, since most of the benefits of higher education are captured by a small segment of
the student population. The government spends US$1,800 per year per student on higher
education, more than ten times what it spends on primary or secondary education. In some
national universities, government subsidies even surpass fees collected from students. More
than 70 percent of the government budget in higher education goes to transfers and capital
expenditures for nine public universities, in sharp contrast with virtually nonexistent
infrastructure projects in primary and secondary schools.
16. The Ministry of Education, Sports and Culture (MOESAC) needs to have a
stronger role in teachers’ management, the largest component in the basic education
budget. It may be worth a consideration providing certain limited benefits and allowances to
motivate teachers to deliver quality education and retain workers in rural areas. But this
should be complemented with tighter staffing rules. Given that teacher absenteeism seems to
be a major problem, steps to both reliably monitor it and penalize absentee teachers (for
example, through payment freezes or reduced chances for promotions) should be explored,
while at the same time resources for supervision should be increased. Within basic education,
there is more room for rationalization in secondary education than in primary education,
which already has a very high pupil-to-teacher ratio. There is also a need for better
coordination among ministries with competence over the basic education sector.
17. Cost reduction policies to increase demand for education and keep children in
school are needed. The Basic Education Assistance Module (BEAM), which provides grants
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for orphans and vulnerable children (OVCs), has shown an impact in increasing school
coverage and thus should be maintained and expanded. At the same time, efficiency gains
should be pursued to reduce costs and consequently user fees, with the ultimate goal of
elimination of fees over the medium to longer term. For instance, some schools are awarded
grants to purchase learning materials in classrooms, but these are often insufficient. Either
these grants should be augmented, or those funds should cease to be earmarked and
channeled to cover overall school expenses that allow institutions to lower school fees. Better
financial recordkeeping in schools should also be envisaged and the staff in charge properly
trained, to ensure proper allocation and utilization of funds provided by the government and
communities. And for the case of school uniforms, cited as one of the reasons for taking
children out of school, it is recommended that MOESAC relax the uniform code, at least
until some of these funding challenges are resolved.
18. There is a need for better coordination among ministries with competence over
the basic education sector. MOESAC is not the only ministry with competence over basic
education. For example, teacher service conditions are determined by the Public Service
Commission, pre-service training is the responsibility of the Ministry of Higher and Tertiary
Education (MHTE), and the BEAM, which covers school fees for vulnerable children, falls
under the jurisdiction of the Ministry of Labor and Social Services. Better coordination and
shared understanding of objectives and priories are critical in implementing sound education
and training policies successfully.
Health
19. Public health expenditures would need to be scaled up to restore essential service
delivery. It is important for the Government of Zimbabwe to consider higher per capita
allocations to the health sector to achieve the short-term goal of revitalizing basic health
services, especially at primary levels. Without such investments, the recovery of the health
sector will likely take longer to achieve, thereby delaying the population’s ability to access
improved health services. The government is currently spending US$20 per capita in the
health sector which is insufficient to cover even the most basic services. The recent strategy
put together by the Ministry of Health and Child Welfare (MOHCW) requires about US$30
per capita. An increase in sector budget should however be contingent upon efficient
utilization of the existing level of resources and re-prioritization within the sector.
20. Within the health sector, budget allocations need to be rebalanced, assigning
more priority to restoring basic health services in rural areas over capital expenditures
in central hospitals in urban areas. A more balanced budget directed toward preventive
health care services and support structures rather than curative care is needed. Currently,
insufficient budget goes to expenditure categories that are likely to have the biggest public
health and development impact, such as mother and child health, and HIV/AIDS, malaria,
and tuberculosis (TB) control, as defined in the MOHCW National Health Strategy.
Therefore, it is critical to resume the provision of basic packages of preventive health care.
Health infrastructure and human resources also need additional budget support to restore
service delivery and guarantee uninterrupted supply of core essential pharmaceuticals and
other medical supplies. Currently, infrastructure, equipment, and treatment in urban central
hospitals greatly outstrip allocations in poor rural areas.
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21. Chronic malnutrition needs to be raised as a policy priority in Zimbabwe. No
intervention is currently in place to address micronutrient deficiencies in infants and young
children, along with promoting appropriate complementary feeding practices. Current
nutrition interventions are short-term and poorly coordinated, have low coverage rates, and
are largely centered on screening and treating severely acutely malnourished children in
health clinics. Chronic malnutrition should be considered a development priority. A long-
term plan to address the problem of stunting in young children needs to be put in place.
22. In terms of other priority areas to focus health interventions, the following are
high pay-off recommendations:
o Increase skilled delivery as well as improve the quality of care provided at
antenatal visits, delivering packages of high impact interventions (for
example, blood pressure machines, weigh scales, hemoglobin meters).
o Maintain essential drugs and medical supplies, and initiate a pharmaceutical
sector reform (including responsibilities of NatPharm).
o Enhance the provision of safe water and sanitation to contribute to the
reduction of morbidity and mortality from diarrheal diseases.
o Revitalize training of health workers, including in-service on-the-job training
(for example, obstetric skills of primary care nurses) and support by senior
medical consultants, especially for district hospital levels.
o Retool, and redeploy these workers at primary care level across the country,
since they yield greater returns for the entire health system
o Rebuild transport and telecommunications for referral and supervisions, and
ensure electricity supply for hospitals and clinics.
o Resume infrastructure works in ongoing health center projects, which should
receive priority in the order of interventions.
o Undertake a health facility assessment to properly determine the current state
of medical equipment and health infrastructure, and help prioritize capital
expenditures.
23. In human resource management, the current donor-funded salary supplements
scheme is unsustainable in the long run and the government should prepare for its
ultimate phase-out, if possible replacing it with a results-based financing framework to
retain workers mainly in rural areas. Donors are contributing to retaining health workers
by providing salary supplements. While these schemes have been successful to stop brain
drain out of certain specializations and less attractive locations, they are unsustainable over
the medium term since they depend on donors’ willingness to continue providing resources.
Moreover, they create tension and expectation among those not participating in the scheme.
The government should come up with an exit strategy by assuming these higher employment
costs in the future. That could also provide an opportunity to start rewarding performance in
service delivery through a results-based financing framework. Also, the role and quality of
village health workers needs to be revamped, including retraining (for example, of primary
care nurses),.
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24. Demand-side interventions could help improve targeting of health services.
Demand-side stimulus to use health services is nonexistent in Zimbabwe. While supply side
efforts are commendable, it is also necessary to ensure that mothers fully understand the
importance of vaccinations to guarantee their children’s good health. Fee waivers for mothers
could be conditional on children completing a full set of vaccinations, providing monitoring
and good record-keeping mechanisms are in place to prevent cheating, along with effective
linking of such information across health care providers (since mothers may visit multiple
clinics). These waivers could be complemented by well-designed health education and
promotion interventions at rural and peri-urban community levels, where most mothers
reside. Similarly, vouchers for transport for woman at risk could be considered, to incentivize
deliveries at the hospital level. Alternatively, the government should consider revitalizing the
Assisted Medical Treatment Orders (AMTOs) vouchers for indigent persons to increase
access to intermediate and tertiary health services.
25. New avenues for private-public partnerships (PPPs) in health care should be
explored. In urban areas, opportunities for private sector participation in hospitals should be
vigorously examined and exploited. Certain priority health services could also be outsourced
to the private sector, and NGOs be contracted to undertake specific tasks for the government.
It is necessary to strengthen partner-private networks in service delivery to reduce
duplication and increase efficiency of the system.
Social Protection
26. It is important to set the building blocks of a social assistance framework that
establishes a minimal livelihood floor below which citizens will not be allowed to fall.
The government needs to use this interim period of fiscal and economic consolidation to
carry out a comprehensive review of social protection framework for its people and
formulate a more integrated and inclusive social protection system. It is possible to
consolidate interventions into a few integrated programs with higher coverage and reduced
administrative costs. With the exception of BEAM, social assistance interventions financed
through the budget are extremely underfunded, with a few programs consuming up to a third
of the social assistance budget on administrative costs alone, and still have negligible
coverage. The Ministry of Labor and Social Services (MLSS) should continue with only a
few of these interventions with meaningful funding and eliminate the rest or leave them for
donor humanitarian assistance.
27. Conditional cash transfers (CCTs) interventions have proven to be very effective
in increasing demand for basic social services, in particular in health and education.
International practices suggest that to maximize the impact of cash or in-kind social
assistance, beneficiaries should be asked to fulfill certain corresponsibilities. These CCTs
experiences are already in place in neighboring countries such as Malawi Mozambique, and
Zambia, and in many other parts of the world. In the Zimbabwe context, the BEAM program
could reduce leakages and have greater impact on school enrollment by transferring
resources to users under the condition of strict education attendance levels (if monitoring and
enforcement mechanisms can allow it), instead of channeling funds to the institutions.
Similarly, the health sector could explore channeling transfers to households in extremely
14
poor areas conditional on their children being fully vaccinated and regularly visiting health
centers. Subsidies delivered through food packages and agricultural inputs could also be
progressively transformed into cash assistance tied to human capital accumulation, to allow
for a more transparent and efficient use of funds. For cases where demand-side constraints
are less of an issue, or poor enforcement mechanisms exist, unconditional transfers would be
more appropriate, given the lower administrative costs and similar impact they may achieve.
28. Resume public works programs, which are an excellent way to transfer
resources to local areas with interventions that support community infrastructure
rehabilitation. Given recurrent natural and economic crises that leave a substantial portion
of the population without access to income or food, and the fact that the country’s physical
and economic infrastructure is in a state of disrepair, it would be wise to set up a scheme that
provides cash (recommended), food, or agricultural inputs in exchange of work requirements
and the rehabilitation of physical infrastructure in periods of crisis. Zimbabwe has
experiences along these lines, like the Drought Relief and Public Works Program, which is
currently underfunded. However, the success of these labor-based relief programs in post-
crisis contexts like the one that Zimbabwe faces rely on solid technical planning, monitoring,
and supervision of projects identified by local authorities and communities. Such projects
could be in the construction and maintenance of local clinics, schools, sewage works, water
systems and roads, but in general should be as labor-intensive as possible to maximize its
local employment impact. Self-selection (willingness to work at the offered wage level) is the
most appropriate targeting mechanism within communities for these types of programs.
29. Overall, additional resources will be needed for social assistance interventions to
make an impact on intended beneficiaries. With help from development partners, the
recommendation is to continue and strengthen BEAM, start piloting conditional cash transfer
schemes, and explore public works intervention to rebuild community infrastructure.
Covering all orphans and vulnerable children in primary education in 2012 would require at
least an additional US$20 million from government sources. A pilot conditional cash transfer
tied to health and schooling requirements to be initiated with 40,000 extreme poor families in
2012 with US$20 in monthly support would require around US$10 million (including
administrative costs). And a pilot six-month public works program for labor-intensive
community projects that target 50,000 participants in rural areas in exchange for US$50 a
month would require around US$20 million (including administrative and material costs). In
the medium term, resources for social protection should aim to reach at least 2 percent of
GDP.
15
I. Introduction
1. Zimbabwe’s economic conditions sharply deteriorated from 2000 to 2008,
mainly reflecting economic mismanagement and the unstable political climate during
the decade. During the period, Zimbabwe experienced political crises accompanied by
economic decline. GDP fell by more than 40 percent between 2000 and 2008 (table 1), and
hyperinflation peaked in September 2008 at about 500 billion percent, before the Zimbabwe
Dollar went out of circulation. While the initial output collapse was widely attributed to
seizure of commercial farms—the backbone of the economy—other factors also contributed:
(i) price distortions due to extensive controls and regulation, particularly relating to the
exchange rate, which was fixed by the Reserve Bank of Zimbabwe at a highly overvalued
rate; (ii) the collapse of investor confidence due to unpredictable policies and deteriorating
property rights, particularly in agriculture and mining; and (iii) minimal external financing
because of poor relations with creditors and donors and deteriorating economic and social
conditions.
Table 1: Selected Macroeconomic Indicators, 2000–10 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009e 2010p
OutputNominal GDP (US$ Millions) 5845 5764 5362 4690 4788 4749 4622 4657 4247 5335 6034
GDP growth (annual %) -5.4 -2.1 -9.0 -16.9 -4.2 -5.7 -3.8 -3.6 -17.3 5.7 8.1
GDP per capita (US$ Millions) 469 461 428 375 383 381 371 374 341 428 432
Overall Fiscal Balance (% of GDP)Revenue and Grants 25.3 19.6 18.0 25.0 34.0 21.7 12.0 4.7 3.1 17.3 29.8
Expenditure 44.0 26.7 20.7 25.3 41.1 33.2 16.1 8.9 6.1 19.6 29.0
Overall Balance (accrual basis, incl. Grants) -18.6 -7.1 -2.7 -0.2 -7.0 -11.4 -4.1 -4.2 -3.0 -2.3 0.8
Inflation and Exchange RateConsumer prices (average annual %) 55.6 73.4 133.2 365.0 350.0 237.8 1,016.7 10,452.6 5.56E+10 6.5 3.6
Official exchange rate
(Z$ per US$, per. avg.) 0.0 0.1 0.1 0.7 5.1 22.4 164.4 9,675.8 6.72E+09 - -
So
urce: World Bank staff calculations based on information from the Ministry of Finance, International Monetary
Fund (IMF) estimates, and World Development Indicators (World Bank).
2. The economic decline has weakened Zimbabwe’s capacity to collect revenues
and finance public expenditures. Government revenue fell from 34 percent of GDP in 2004
to 3.4 percent of GDP in 2008. Central government expenditure shrank from about 44
percent of GDP in 2000 to 5.7 percent of GDP in 2008, causing an almost complete collapse
in the provision of public services. The economic decline also derived led to a balance of
payment crisis, including external debt default, which has closed the access to external
financing. Zimbabwe is in current account and debt distress. The current account deficit is
estimated at 18.3 percent of GDP in 2010, and external debt at 102 percent of GDP.
Moreover, Zimbabwe is on nonaccrual status (of loans and grants) with the International
Monetary Fund (IMF), the World Bank, and the African Development Bank due to the
accumulation of payment arrears and loans. Unless a strategy for arrear clearances is
implemented, the government will not be able to access financing from these or other
international financing institutions.
16
3. Economic collapse severely impacted social well-being. As a consequence of 10
consecutive years in recession, the current estimated GDP per capita of US$432 places
Zimbabwe as one of the poorest countries in the world. More than half the population is
submerged in poverty. While recent official poverty figures are not available, given the lack
of reliable household-level data, poverty is likely to be much higher than the latest available
data (from 2003), when 53 percent of the urban population and 63 percent of the rural
population was living below the food poverty line. By contrast, in 1995, before the economic
crisis, poverty rates were 31 percent and 53 percent in urban and rural areas, respectively.
4. The crisis also decimated fiscal resources of the government, and thus
compromised social service delivery. With funding at minimum levels, by the end of 2008
most schools and many hospitals closed, and transport and electricity networks were severely
compromised. The cholera outbreak in 2008 is testimony to the country’s collapsed
infrastructure in water sanitation; around 100,000 cholera cases have been reported.
Zimbabwe’s health system—which was referred to as the leading example in Africa after
achievements in the 1980s—was severely hit by the crisis and has not fully recovered since
then. It is characterized by a deficit of medical and managerial health professionals, severe
shortage of essential drugs and medical supplies, inadequate provision and maintenance of
equipment and infrastructure, and dilapidated transportation (an ageing fleet of ambulances
and service vehicles in the health sector) and telecommunications systems (nonfunctioning
fixed telephone line system, nonfunctioning high frequency radio system). Problems are
especially great at the primary care level in rural areas, which impacts on the entire system,
given its linkages with the upper levels. Similarly, the education system—which was widely
seen as one of the strongest in Africa until the 1990s— is today in a crisis that is reflected in
insufficient learning materials, dilapidated school infrastructure, and low credibility of the
national examination system. The human resource situation in these sectors is particularly
serious, since many qualified doctors, nurses, and teachers have left the country, given
current salaries. The government-financed social protection program is currently inadequate
to cushion the increasing numbers of poor and vulnerable groups (orphans, disabled, elderly),
except the Basic Education Assistance Module (BEAM), which too suffers from chronic
underfunding.
5. The human cost of the economic, political, and fiscal crisis has been catastrophic,
as reflected in a number of social indicators. Life expectancy at birth declined from 61
years in 1990 to 43 years in 2008. Infant mortality rose from 51 per 1,000 live births in 1990
to 60 in 2009, under-five mortality from 79 per 1,000 live births to 86, and maternal
mortality from 168 cases per 100,000 births to 725 in the same period (see table 2). Around
22 percent of children are orphans (one or both parents dead), most of them cared for by
elderly who do not have access to pension payments or other forms of public social transfer
payments as in some countries in the Southern African region. Although school enrollment
rates are still high by African standards, many children are dropping out of school since their
families cannot afford the required school fees. The retention of doctors and teachers,
particularly in rural areas, has been difficult due to low salaries and brain drain to
neighboring countries. At this rate, Zimbabwe is not likely to achieve the Millennium
Development Goals (MDGs) by 2015, in particular those related to universal primary
17
education, access to reproductive health, and access to treatment for HIV/AIDS, as well as
reductions by two-thirds in infant mortality, and by three-quarters in maternal mortality.
Table 2: Selected Social Indicators, 1990–2009 1990 1995 2000 2003-2005 2006-2009
Population
Population (millions) 10.5 11.7 12.5 12.5 12.5
Population ages 0-14 (%) 46.1 44.3 42.2 41.2 40.5
Population ages 15-64 (%) 51.0 52.5 54.4 55.1 55.5
Population ages 65 and up (%) 3.0 3.1 3.4 3.7 3.9
Rural population (% of total population) 71.0 68.3 66.2 64.5 63.1
Fertility rate, total (births per woman) 5.2 4.4 3.9 3.7 3.5
Adolescent fertility rate (births per 1,000 women ages 15-19) .. .. 87.6 70.9 64.6
Health Indicators
Life expectancy at birth, male (years) 57.5 49.2 40.6 39.9 42.6
Life expectancy at birth, female (years) 64.3 57.5 46.2 42.6 43.7
Mortality rate, infant (per 1,000 live births) 50.6 55.2 65.0 60.0 60.0
Mortality rate, under-5 (per 1,000) 79.3 90.6 102.1 82.0 86.0
Maternal mortality ratio (per 100,000 births) 168.0 .. 578.0 555.0 725.0
Prevalence of HIV,adult (% of population aged 15-49) 14.2 27.3 28.0 18.1 13.7
Immunization, measles (% of children ages 12-23 months) 87.0 87.0 75.0 56.0 69.0
Immunization, DTP3 (% of children ages 12-23 months) 88.0 88.0 76.0 64.7 62.0
Physicians (per 1,000 people) 0.1 0.1 0.1 0.2 ..
Access to an improved water source (% of population) 78.0 79.0 80.0 80.0 73.0
Access to improved sanitation facilities (% of population) 44.0 45.0 45.0 .. 46.0
Educational Indicators
School enrollment, primary (% net) .. .. 98.0 96.0 91.0
School enrollment, secondary (% net) .. .. 51.0 46.0 ..
School enrollment, tertiary (% gross) .. .. 3.6 3.8 ..
Pupil-teacher ratio, primary 35.8 39.1 37.0 37.7 40.0 Source: Multiple Indicator Monitoring Survey (MIMS) 2009; Ministry of Health and Child Welfare (MOHCW)
2009; World Development Indicators (World Bank).
6. With economic recovery, the situation in social service delivery has mildly
improved, but not attained pre-crisis levels given chronic underfunding of social
sectors. The increased funding is primarily going to pay salaries, with low amounts directed
toward other critical expenditures, such as books in the education sector, or medicine in the
health sector. Users are being asked to contribute significantly to direct out-of pocket
payments for services. Donor financing continues to be critical to ensure continuity in the
provision of essential services. Several challenges lie ahead in social sectors that will require
revisiting the adequacy and impact of social spending to achieve meaningful progress. For
instance, in education, literacy rates continue to be high, but overall net enrollment rates—
particularly in secondary education—have declined. In health, child mortality and stunting
continues to be high, as well as maternal mortality and prevalence of communicable diseases.
Most households lack a public or private safety net to protect incomes from shocks and
guarantee access to minimal services. Unless these factors are tackled, they will have a long-
term impact on the development of human capital.
18
7. Importantly, the government still lacks an explicit medium-term reform agenda
that would help prioritize public expenditure within each of the social sectors. There is
still room to reallocate resources within social sectors, in particular to nonwage expenditures.
For example, alternative private funding sources for higher education (user fees) could be
explored to liberate resources for primary and secondary schools, in particular for school
material and infrastructure. In health it would produce greater overall health benefits if
primary health care in district and rural regions is given priority, over urban central hospitals,
unlike the current practice. However, there is absence of explicit statement of sector goals
and objectives and programs, and interventions that would support such goals and objectives,
to inform prioritization. Today, with the exception of health, which recently produced its
comprehensive medium-term strategy with donor support, budget proposals from social
sector ministries appear not to be directly linked to major objectives and indicators of
medium-term strategy. Line ministries have low capacity to contribute to the planning
process and identify priorities to finance with the scarce available resources. As with the rest
of the public administration, the Public Finance Management System (PFMS) in social
sectors is still experiencing severe implementation challenges.
II. Recent Trends in Social Expenditures
8. Since 2005 the available resources allocated to the social sectors have eroded.
Before the period of hyperinflation, in 2005, the Government of Zimbabwe used to spend
more than 15 percent of GDP on social expenditures (figure 1). Of this amount, around 8.5
percent was allocated to basic education, 4 percent to health, 2.5 percent to higher education,
and 0.5 percent to social protection. The economic collapse and hyperinflation left social
sectors with limited funding from public sources, and by 2009 social public expenditures
accounted for only 6 percent of GDP, with education and health sectors experiencing budget
cuts of more than a half of those allocated in 2005.
9. The situation has improved somewhat since 2009, with the recovery in collection
of revenues and allocation of additional resources to social sectors. With macroeconomic
stabilization, the economy grew again in 2009 by 5.7 percent, and by an estimated 8.1
percent in 2010; consequently, tax collections also rebounded, and the government avoided
the quasi-fiscal financing practices of previous years. Government revenues jumped from 3.4
percent in 2008 to 17.3 percent of GDP in 2009, and are projected to reach 29.8 percent in
2010. But the public sector still faces hard choices to meet competing demands within a
severely constrained budget.
10. Following the recent recovery of revenues, social sectors are receiving more
public resources than before, but their share of the total government budget is well
below their pre-crisis levels. In 2010, budgeted resources to social sectors reached 11.6
percent of GDP, almost twice as much as in 2009. This has helped resume essential social
service delivery. Moreover, for 2011 the government has recently announced that resources
to social sectors will reach 16 percent of GDP, as it was in 2005. The recovery is spread
across sectors: basic education now accounts for 7.8 percent of GDP (compared to 3.5
19
percent in 2009); health, 4.3 percent (compared to 1.5 percent in 2009); higher education, 2.6
percent (compared to 0.5 percent in 2009); and social protection, 1.3 percent (compared to
0.5 percent in 2009). Still, social sectors in 2011 will represent only 35 percent of the budget
(17.1 percent in basic education; 5.7 percent in higher education; 9.3 percent in health; and
2.9 percent in social protection), well below the level of 45 percent during the first half of
2000s, or even the 42 percent reached in 2009. Aside from social protection, the rest of the
sectors (basic education, higher education, and health) have experienced reductions in budget
shares with respect to other ministries/areas (figure 2).
Figure 1: Social Public Expenditures, 2005, 2009, 2010, and 2011
0
2
4
6
8
10
12
14
16
18
2005 2009 2010 2011
% o
f G
DP
Social Protection
Higher Education
Basic Education
Health
Sou
rce: Ministry of Finance.
11. Moreover, budgetary allocation toward social sectors has been quite volatile,
with budgeted funds failing to materialize when revenues are less than expected. Aside
from experiencing relatively low budget allocations in recent years, compared to pre-crisis
levels, actual disbursements of funds to social sectors have suffered drastic cuts when
expected government revenues fail to materialize. While differences between budget
allocations and actual disbursements tend to occur across all ministries, these discrepancies
are magnified in social sectors. For instance, in 2009, the health sector received 65 percent of
the budgeted allocation, and social protection received only 40 percent of its respective
budget, when resources were 30 percent less than originally planned. Aside from revenue
shortfalls or poor revenue forecasts, these discrepancies can in part be explained by low
budgeting execution capacity, in particular of capital expenditures.
Figure 2: Social Public Expenditures by Sector, 2000–11
20
0
5
10
15
20
25
30
35
40
45
50
2000 2001 2002 2003 2005 2006 2007 2009 2010 2011
% o
f Gov
ernm
ent
Budg
et
Social Protection Health Higher Education Basic Education
Source: Ministry of Finance.
12. As in many other countries, employment costs are the largest expenditure
category in social sectors. Overall, the largest budget lines for social sectors are wages,
salaries, and pension payments (box 1). Excluding wages of civil servants in social
ministries, teachers, and health workers, social public expenditures accounted for just 11.3
percent of the expenditures in 2009, an historical low (figure 3). Since 2010, however, efforts
to contain civil service salaries and employment have allowed the government to make room
for additional nonwage social sector expenditures. Nonwage expenditures will account for
15.4 percent of the budget in 2011, more in line with the decade average.
Figure 3: Social Public Expenditures, 2000–11
0
5
10
15
20
25
30
35
40
45
50
2000 2001 2002 2003 2005 2006 2007 2009 2010 2011
% o
f Bud
get
SPEs SPEs Excluding Wages
Source: Ministry of Finance.
Box 1: The Recent Increase in the Wage Bill in Public Expenditures
21
The 2009 macroeconomic stabilization included an upward adjustment of government wages and
salaries in Zimbabwe, raising them to a flat rate of $100 per month across levels and categories.
Although the action helped improve living standards and morale of the approximate 200,000 civil
servants, and further adjustments and salary decompression took place between 2009 and 2011, they still
remain at low levels compared to historical standards and private sector remuneration. But fiscal
challenges prevent further increases in civil service remuneration if urgent infrastructure projects and
social programs will resume.
Moreover, despite a shrinking economy, civil service established posts and staff in position in Zimbabwe
have been increasing at a sustained pace since 2004 (see table). Between 2004 and 2009, established
posts increased by almost 19 percent, or about 3.5 percent per year. The increase in established posts was
concentrated in the Ministry of Agriculture (14 percent annual increase), Ministry of Higher Education
(4 percent annual increase), and the Ministry of Youth Development, Gender and Employment Creation
(26 percent annual increase). As of 2009, education and health workers accounted for 77 percent of civil
servants. While it is not easy to identify the drivers of the increase in civil service employment, it may
partially reflect the fact that between 2004 and 2009 nearly 14 additional ministries were created. Some
of these were the result of splitting up existing Ministries (for example, the Ministry of Public Service,
Labor and Social Welfare into the Ministry of Public Service and the Ministry of Labor and Social
Services), while some were entirely new (such as the Ministry of Regional Integration).
Civil Service Established Posts and Staff in Position
Year Established
postsa
Staff in Positiona
Total
As a % of
established
posts
Education
and higher
education
Health
Education
and health
as % of
total
2004 176,506 161,878 91.7 114,165 23,390 85.0
2005 189,392 159,558 84.2 108,865 23,860 83.2
2006 193,386 163,974 84.8 109,803 26,375 83.0
2007 193,386 178,229 92.2 118,970 27,596 82.2
2008 201,220 180,188 89.5 117,313 26,342 79.7
2009 209,371 182,147 87.0 115,655 25,088 77.3
2010 (budget) 200,389
Source: World Bank (2010).
a, Excludes military and staff of GIA institutions
The pay raise for civil servants may result in an unaffordable increase in the wage bill, which is already
higher than those in low-income neighboring countries such as Malawi, Mozambique, and Zambia (see
figure). Still, further decompression of the wage scale is justified to improve motivation and retention of
skilled civil servants. The government could consider decompressing the wage scale while maintaining
the wage bill within a fully financed budgetary environment in order to reduce the wage bill in the
medium term. The authorities are also conducting a government payroll audit with a view to removing
unaccounted workers (―ghost workers‖).
A sustainable fiscal strategy over the medium term would involve holding the wage bill at around 40
percent of revenue, and to less than 10 percent of GDP. The hyperinflation of the decade effectively
reduced the wage bill to 1.3 percent of 2008 GDP, but now is again way above these targets (52 percent
of revenues, and 18 percent of GDP for 2011). There has traditionally been a well-established system of
wage negotiations between the government and the civil service unions. This system makes it difficult
not only to lower the wage bill but also to restructure the civil service.
Wage Bill, Selected African Countries, 2009
22
a. Wage bill in U.S. dollars
0
200
400
600
800
1,000
1,200
2000 2005 2009e
Co
nst
an
t 2
00
0 m
illi
on
s U
S$
Zimbabwe Malawi Mozambique Zambia
b. Wage bill as percent of total expenditure
0
5
10
15
20
25
30
35
40
45
2000 2005 2009e
% o
f To
tal
Ex
pe
nd
itu
re
Zimbabwe Malawi Mozambique Zambia
Source: Authors’ elaborations based on World Bank (2010).
Education
13. While all social sectors have suffered from severe budget cuts since 2005, basic
education has been the most affected. Zimbabwe has traditionally be one of the more
educated countries in Sub-Saharan Africa, as a result of substantial efforts toward investing
in public education. The bulk of funding for basic (primary and secondary) education in
Zimbabwe comes from the central government. Schools also earn income from student fees
and levies, and obtain resources from other income-generating activities, and in some cases
from private or donor support. While in 2005 Zimbabwe was spending 8.5 percent of its
GDP and 26 percent of the budget on public primary and secondary education, resources to
the sector will amount to 7.8 percent of GDP and just 17.1 percent of total expenditures in
2011. In 2011, the Government of Zimbabwe will spend just US$115 per primary student per
year, and US$200 per secondary student, which are well below the US$800 and US$1,000
respectively spent in South Africa or other neighbors in the southern region (figure 4).
Despite these funding challenges, Zimbabwe is still able to allocate resources to basic
education at a much higher proportion than countries with similar income levels in the region
(figure 5).
14. High employment costs barely leave any room for nonwage government
expenses in basic education. Teachers across all levels of education represent around 68
percent of all civil servants in Zimbabwe, with 60 percent of them working in primary
education, 35 percent in secondary education, and the rest in tertiary education and
administrative tasks.1 In basic education, 96 percent of the budget in 2009 corresponded to
employment costs, which crowded out other expenses (notably capital expenditures, which
were completely cut off) due to a revision in teachers’ salaries in the course of the year. This
is not surprising, since nonwage expenditure components (transfers, programs, and capital
expenditures) are usually easier to cut when resources fail to materialize. Staffing rules also
pose significant challenges to containing the wage bill in education. Teachers are entitled to
vacation, maternity, and sick leave at full salary for up to 90 days or at partial pay depending
1 World Bank (2007).
23
on the duration thereafter. During the absence, relief staffs are recruited, resulting in two
people being paid for the same position. This, along with increasing cost of salaries in
general, has the net effect of reducing total expenditure for operations and teaching materials,
which ultimately compromises the quality of education. According to the 2011 budget,
nonwage expenditures will represent only 13 percent of the sector budget, to cover school
examinations, transfers to private schools, teacher’s training, textbooks, and limited school
infrastructure and rehabilitation (less than 4 percent of the budget) (table 3).
Figure 4: Expenditure per Student, Basic Education, Zimbabwe, 2011, and Sub-
Saharan Africa, Average 2005–08
0
100
200
300
400
500
600
700
800
900
1000
Bo
tsw
ana
Sou
th A
fric
a
Nam
ibia
Mau
riti
us
Swaz
ilan
d
Leso
tho
Ke
nya
Sen
ega
l
Bu
rkin
a Fa
so
Zim
bab
we
(2
01
1)
Nig
er
Mau
rita
nia
Gh
ana
Mal
i
Cam
ero
on
Mo
zam
biq
ue
Uga
nd
a
Ch
ad
Zam
bia
Rw
and
a
Togo
Mad
agas
car
Eth
iop
ia
Erit
rea
Bu
run
di
Gu
ine
a
Lib
eri
a
$ p
er
stu
de
nt
pe
r ye
ar
Primary Education
0
500
1000
1500
2000
2500
3000
Bots
wan
a
Swaz
iland
Mau
ritiu
s
Sout
h A
fric
a
Nam
ibia
Leso
tho
Cam
eroo
n
Moz
ambi
que
Sene
gal
Mau
rita
nia
Mal
i
Zim
babw
e (2
011)
Gha
na
Nig
er
Chad
Keny
a
Uga
nda
Burk
ina
Faso
Rwan
da
Buru
ndi
Togo
Mad
agas
car
Zam
bia
Ethi
opia
Eritr
ea
Libe
ria
Gui
nea
$ pe
r stu
dent
per
yea
r
Secondary Education
Sou
rce: World Bank staff calculations based on World Development Indicators.
Figure 5: Public Spending on Basic Education (Percent of GDP), Zimbabwe, 2011, and
Sub-Saharan Countries, Average 2003–08
24
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
- 1,000 2,000 3,000 4,000 5,000 6,000 7,000
Pub.
Exp
. in
Basi
c Ed
ucat
ion
(% o
f GD
P)
GDP per Capita
ZWE
Source: World Development Indicators and Ministry of Finance.
Table 3: Expenditures in Basic Education (Percent of 2011 Sector Budget)
All Areas 87.3 3.8 4.0 1.6 3.2 469,367,000
Administration and General 0.9 1.2 0.1 0.2 - 2.3
Education Coordination and Development 0.2 0.5 0.5 1.2 - 2.3
Primary Education 56.7 0.9 1.4 0.1 2.1 61.2
Secondary Education 29.4 1.1 1.3 0.1 1.1 33.0
Sports, Arts, and Culture 0.1 0.2 0.8 - - 1.1
Areas
Recurrent Expenditures Capital ExpendituresTotal
ExpendituresEmployment costsGoods and
Services
Transfers and
Programmes
Fixed capital
assets
Capital
Transfers
Sou
rce: Ministry of Finance.
15. The government operates a decentralized policy for public education
management and financing. The economic crisis in the 2000s resulted in the government
adopting a policy of decentralization that transferred ownership of schools to the
communities.2 With ownership, the government also transferred the bulk of the responsibility
for maintenance and extension of existing schools and the cost of construction of new
schools to School Development Committees and Parent-Teacher Associations. Within this
decentralized framework, the central government pays for teacher salaries and allowances,
and provides a per student grant to schools and tuition grants to nongovernment schools for
the purchase of books and learning materials. The allocation of government grants is, to a
large extent, based on available government revenues rather than the actual cost of the
pedagogic materials. All government schools charge school fees, which are set higher for
children in low-density area schools and lower for children in high-density and rural school.
The difference is compensated by the government through an ―equalization grant,‖ which is
given to schools in high-density areas to compensate for the lower fees they charge. These
2 World Bank (2007).
25
grant amounts, however, are small and usually disbursed with substantial delays. Rural
schools, mainly under the jurisdiction of District Councils, do not receive such assistance.
16. School fees and levies constitute a major source of financing education in
Zimbabwe. Schools are currently earning income from student fees and levies. Levels must
be approved by Provincial Education Directors. In 2009, annual tuition fees for primary
schools ranged from US$15 to US$20 in urban high-density areas, while tuition fees for
secondary schools ranged from US$15 to US$100.3 Levies varied from urban and semi-urban
to rural areas and also by type of school, from US$3 to US$60 in primary schools, and US$5
to US$50 in secondary schools.4 Schools are allowed to use student fees and levies to support
operations (such as education materials and repairs) and supplement salaries to retain
teachers. Similarly, the Zimbabwe School Examination Council (ZIMSEC), a parastatal
responsible for the administration of national exit examinations in primary and secondary
education, is also allowed to charge examination fees to secondary students (US$5 per
subject for Ordinary level, and $20 for Advanced level).5 The institution conducts
examinations for Grade 7 in primary education, and Ordinary and Advanced level candidates
for secondary education. Data for 2004 indicate that households spent an average of US$87
on primary and US$105 on secondary education (in 2010 dollars), close to the government’s
outlay of US$96 and US$169 for that year.6 Household survey data for 2007–08 show that
households with children attending school consumed on average 10.2 percent of their budget
on school fees, uniforms, and other expenses, up from 8.8 percent in 2001.7 Many calls have
been made for public school fees and levies to be abolished; however, the challenging
macroeconomic environment and lack of sufficient public funds will create additional
pressures for increased private support.
17. Local governments and donors are also increasingly financing basic education
expenses. Local authorities and church organizations provide complementary funding to the
schools they administer or support. The Ministry of Local Government, and Urban and Rural
Development also disburses limited funds for renovations and building of infrastructure at
schools. Individuals, nongovernmental organizations, and corporations also provide direct
financial and material support to students and schools. For instance, the Education Transition
Fund (ETF), established in 2009, provides core curriculum textbooks, stationery, and
teaching and capacity development for primary and secondary education. In 2010, the
government expected US$36 million in donor contributions to the basic education sector,
through US$28 million from ETF and US$8 million to help rehabilitate school infrastructure,
though just US$1 million has been disbursed in the first semester of 2010.
18. Funding for higher and tertiary institutions in Zimbabwe comes from four main
sources. Government income comes in the form of direct support to institutions. The second
income source comes from tuition and examinations fees and other levies. In public
institutions, government also provides cadetship funds for eligible students who demonstrate
3 Chakanyuka, Chung, and Stevenson (2009).
4 UNICEF (2010).
5 UNICEF (2010).
6 World Bank (2007).
7 World Bank staff calculations based on the Income, Consumption and Expenditure Survey (ICES) 2001 and
2007, collected by the Zimbabwe National Statistical Agency (ZIMSTAT).
26
financial need and qualify for government assistance. The amount of private funding varies
from one institution to another depending on fundraising capacity and the relationships an
institution develops with prospective supporters. Institutions also generate income from
various projects and activities such as production units, hiring services, and facilities, and
returns on saving schemes and investments. Unlike primary and secondary education, the
higher and tertiary education subsector does not count on significant donor support, except
for charitable organizations, churches, corporations, and private individuals that provide
scholarships directly to students.
19. Despite funding challenges, there has been a shift of public resources toward
higher education. The higher and tertiary education sector experienced funding challenges
as the rest of the social sectors, though government transfers in 2011 will recover to 2005
levels, at 2.6 percent of GDP. The sector as a whole has experienced a significant gain in its
share of public spending, from 3.2 percent of the budget in 2009 to 5.7 percent in 2011. With
an estimated enrollment of 87,000 students in public universities, polytechnics, and teachers’
colleges, Zimbabwe is currently spending an average of US$1,800 per year per student on
higher education (including all administrative costs), which is high by African standards and
higher than it was in 2004 (US$1,680 per student, in 2010 dollars).
20. More than two-thirds of the government budget in higher education goes to
transfers and capital expenditures for nine public universities. Of the total transfers to
tertiary institutions, three-quarters of them goes to universities, and the remainder to
polytechnics and Teacher Training Colleges (TTCs), which account for 32 percent of the
enrollment in higher education. Half of the budget of the Ministry of Higher Education goes
to pay for operations in nine public universities (University of Zimbabwe; National
University of Science and Technology; Midlands State University; Zimbabwe Open
University; Great Zimbabwe University; Chinhory University of Technology; Bindura
University of Science and Technology; Harare Institute of Technology; and Lupane State
University). The government is also allocating important resources to capital expenditures for
tertiary institutions—20 percent of its budget—a sharp contrast with projects in primary and
secondary schools (table 4).
21. The public sector is still the main income source for university institutions to
cover operations. Nongovernment income from fees, donations, levies, and income
generation activities varies substantially across university institutions, but in most cases it is
low compared with financing received from the public budget. In 2009, the general cost of
tuition fees at the university level was US$300 per semester for arts degree courses, US$400
for science and engineering, and US$400 for medicine and veterinary sciences. As expected,
fees at private universities are much higher than at public universities. Similarly, fees at
polytechnics are slightly higher than the fees charged by state universities (no information is
available for fees at teacher training colleges). Data from two national universities (National
University of Science and Technology and Chinhory University of Technology) show that
tuition fees collected were one-third lower than the amount received from government
transfers. In contrast, data from Harare Polytechnic present a different picture: its collection
of tuition fees were 14 times more than public transfers.
27
Table 4: Expenditures in Higher Education (Percent of 2011 Sector Budget)
All Areas 8.4 1.1 70.1 4.3 16.1 156,767,400
Administration and General 1.9 1.1 66.2 0.1 16.1 85.3
National Universities 54.5 16.1
National Education and Training Fund 9.6
Scholarships 1.3
Others 0.9
Teacher Education 4.2 - 1.2 1.3 - 6.6
Technical Education and Training 2.3 - 2.7 3.0 - 8.0
Areas
Recurrent Expenditures Capital ExpendituresTotal
ExpendituresEmployment costsGoods and
Services
Transfers and
Programmes
Fixed capital
assets
Capital
Transfers
Sou
rce: Ministry of Finance.
Health
22. The health sector has also suffered from chronic public underfunding since the
economic collapse, although the government is taking steps to assign additional
resources to the sector. Before the crisis, the public sector was spending around 4 percent of
the GDP on the health sector, among the highest rates in Sub-Saharan Africa. By 2009, this
share had fallen to 1.5 percent. In a commendable effort, the government has increased
resources to reach 4.3 percent of GDP in 2011, which is even higher for the relative size of
the economy than neighboring countries (figure 6). Still, on a per capita basis, the
government will allocate only US$20 per habitant in 2011 on health, which is close to the
regional average but once again far away from the situation of close neighbors like South
Africa or even Zambia, which spend US$200 and US$300, respectively, per capita on public
health (figure 7).
23. Public spending in the health sector is also mostly driven by employment costs,
but less so than in the education sector. With approximately 35,000 health workers, from
2009 to 2011, employment costs absorbed 32–35 percent of the health budget, much less than
in the case of education and more in line with international standards (table 5). Basic salaries,
in line with the rest of the public administration, are not high enough to retain qualified
personnel with more attractive outside options in private clinics and abroad. To retain health
workers, donors—mainly the United Kingdom Department for International Development
(DfID) through the Global Fund—are contributing salary supplements to health workers
above a certain grade (―health retention schemes‖): a monthly tax free ―retention allowance‖
of up to 70 percent of base salaries is paid directly to 13,000 health workers employed by the
central government or in mission hospitals, based on confirmed attendance to work. The
retention allowance is also used to cover municipal health workers, until they started to
receive higher salaries (since they are not subject to the central government salary scale). The
health retention scheme budget for 2009 was US$20 million, equivalent to 40 percent of the
total government employment costs in health. Although this scheme has been successful in
retaining critical health personnel, it is at creating tension among those not covered by the
program, and is unsustainable in the long run. The Results-Based Financing program
currently under preparation by the government and donors will link performance to financing
28
by providing performance grants tied to the delivery of core maternal and child health
services in health care clinics and rural health centers.8
Figure 6: Public Expenditure in Health (Percent of GDP), Zimbabwe, 2011, and Sub-
Saharan Countries, Average 2003–08
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
- 1,000 2,000 3,000 4,000 5,000 6,000 7,000
Pub.
Exp.
in H
ealth
(% o
f GDP
)
GDP per Capita
ZWE
Source: World Development Indicators and Ministry of Finance.
Figure 7: Per Capita Public Expenditure on Health, Zimbabwe, 2011, and Sub-Saharan
Africa, Average 2005–07
0
50
100
150
200
250
300
Bot
swan
a
Sou
th A
fric
a
Nam
ibia
Mau
ritiu
s
Swaz
iland
Zam
bia
Leso
tho
Sene
gal
Zim
bab
we
(2
01
1)
Gha
na
Burk
ina
Faso
Rw
and
a
Chad
Mal
i
Mau
rita
nia
Moz
ambi
que
Cam
eroo
n
Ke
nya
Mad
agas
car
Nig
er
Uga
nd
a
Togo
Buru
ndi
Ethi
opia
Eritr
ea
Libe
ria
Gu
ine
a
$ p
er
cap
ita
pe
r ye
ar
Source: World Development Indicators and Ministry of Finance.
Table 5: Expenditures in Health (Percent of 2011 Sector Budget)
8 The RBF program will start in 2011, and will focus on the rural districts in Zimbabwe. Its impact will be
assessed through a rigorous impact evaluation.
29
All Areas 34.5 5.1 42.0 14.4 4.0 256,198,000
Administration and General 0.6 1.9 0.8 10.7 0.0 14.1
Medical Care Services 29.0 0.7 36.7 3.6 4.0 74.1
Local Authorities 6.6
Mission Hospitals 9.0
Parirenyatwa Group of Hospitals 6.7
Government Hospitals 13.8
Others 0.7
Preventive Services 3.2 2.3 4.3 0.0 0.0 9.9
Research 1.6 0.2 0.2 0.0 - 2.0
Recurrent Expenditures Capital ExpendituresTotal
ExpendituresEmployment costsGoods and
Services
Transfers and
Programmes
Fixed capital
assets
Capital
Transfers
Areas
Source: Ministry of Finance.
24. Progress is being made—at least in central hospitals—in resuming public
provision of critical drugs and medicines and infrastructure maintenance. Medical
supplies are grossly under-budgeted. Just 0.6 percent of the health budget goes to finance
drugs and medicines, a striking contrast with the 13 percent spent in 2003. Still, the
government at least resumed provision of some drugs, medical equipment, and other medical
supplies to nine central hospitals in 2010. Other health institutions, including mission
hospitals, receive minor transfers not comparable to those allocated to central institutions
such as provincial and central hospitals, and hence cannot cover even basic inputs. The
government also collects an ―AIDS Levy‖ that consists of the 3 percent collected from every
worker’s taxable income (Pay-As-You-Earn) and from the corporate tax, to earmark funds
for prevention, orphan care, and procurement of medicines for the prevention the
transmission of AIDS from parent to child.
25. Currently, there is an over-emphasis on funding fixed capital assets as opposed
to service delivery. Around 18 percent of the health budget goes to capital expenditures and
capital transfers to central hospitals. Allocations to fixed capital assets (particularly
transportation and infrastructure) greatly outstrip allocations for targeting resources to
restoring health services and addressing the needs of vulnerable groups (through transfers to
rural areas, for example). Priority is not necessarily given to complete ongoing infrastructure
projects [[that had suffered from]] inadequate funding, which have the greatest marginal
returns. In general, too little of the total budget goes to expenditure categories that are likely
to have the biggest public health and development impact, such as mother and child health,
and HIV/AIDS, malaria, and TB control. Expenditures at the primary and secondary levels,
where a majority of the population seek health services, are low, and are not likely to have
the desired effect of revitalizing a robust preventative care approach as well as the necessary
support structures at community levels.
26. Nearly all the public funds for health go to curative services, and negligible
amounts go to preventive services. Nearly 90 percent of the central government transfers go
to curative services, just 10 percent goes to finance preventive services, and almost no
resources are available for research. These ratios are not much different from those registered
in 2006, when 85 percent of government transfers were allocated to curative care. There is a
need to revitalize both preventative services and rebuilding of critical structures for
delivering preventive services. Preventive services such as antenatal care, childhood
30
immunization, health education, family planning, nutrition, and environmental health
services are nowadays provided mostly by districts and donors, which finance the bulk of
drugs drug and medicine purchases and medical supplies. Funding is also needed to revitalize
the role of village health workers, who provide disease surveillance and help to follow up
community-based patients on behalf of health facilities. Lack of resources for preventive care
is worrisome, since preventive care is more cost-effective than curative care. Moreover,
curative care tends to benefit a minority of the population (urban and better-off), compared
with preventive services, which also reach poor and rural areas. Budget allocations are not
based on an appreciation of the disease burden and evidence-based interventions that will
address the disease burden.
27. Donors have historically contributed significantly to the health sector in
Zimbabwe. Even before the economic crisis, donors were contributing significant resources
to health financing, accounting for 12 percent of total expenditures in 1995.9 By 2005, donor
assistance was already equivalent to overall government financing. In 2009, donors
contributed around $118 million in programs (HIV, maternal care, malaria, and cholera
prevention), drugs, vaccinations, and salary supplements. For 2010, donors pledged to
contribute around $159 million, once again equivalent to the overall government budget for
the sector (table 6). However, only $27 million had been made available in the first semester
of the year (mainly for expanded support programs, HIV/AIDS, and drugs).
Table 6: Expected Donor Assistance in Health, 2010 (US$ millions)
Source: Ministry of Finance.
28. Out-of-pocket spending accounts for half of total health spending. Zimbabwe
introduced user fees for publicly provided health services in the beginning of the 1990s.10
The co-payments required include fees for visits to secondary and tertiary public hospitals
and clinics, if the patients are not referred from primary care centers. User fees also include
fees for laboratory tests, inpatient days, and medicine. Estimates for 2004 showed that out-of-
pocket spending accounted for 55 percent of health expenses, in both the public and private
sectors. There is some evidence that out-of-pocket spending could have increased during the
crisis. Household survey data for 2007 show that for those households that had health
expenses, such expenses consumed on average 6 percent of the household budget (up from 4
percent in 2001).11
This relatively high percentage could reflect the decline in publicly
provided drugs and other services. Although data are inexistent, anecdotal evidence indicates
9 World Bank (2007).
10 World Bank (2007).
11 World Bank staff calculations based on ICES 2001 and 2007.
HIV/AIDS, TB and Malaria Drugs 81,197,587 Other Drugs and Medical Supplies 36,450,000 HIV/AIDS mitigation 18,000,000 Expanded Programme on Immunization 15,400,000
Capacity Building 7,460,000
Total 158,507,587
31
that the high user fees constitute a major barrier for access to health services, and user fees
are likely to be an important contributor to the declining health status of the population.
29. The Ministry of Health and Child Welfare has set up a medium-term strategy
for the recovery of the health sector. In a commendable effort and unlike most other
government ministries, the Ministry of Health and Child Welfare (MOHCW) has produced a
medium-term recovery strategy called ―National Health Strategy, 2009–2013.‖12
This
strategy has been developed through consultation with key stakeholders in health, including
government, development partners, civil society, and the private sector. It is expected to
guide future government budget allocations to the sector, as well as identify financial gaps to
guide donor interventions, and represents a shift from the previous emergency planning mode
to restoring basic service delivery in the health sector. The major thrust of the medium-term
strategy is ―to revitalize the health sector, identify high impact priority interventions and
mobilize additional resources to scale up progress towards attainment of MDGs.‖ To achieve
these goals, the focus is on: (i) keeping as many people as possible in good health in the
community through health protection, health promotion, and disease prevention strategies;
(ii) providing appropriate quality services for those needing care in the community (primary
care); and (iii) providing high quality hospital services at the appropriate level for those few
requiring that form of treatment and care. To achieve substantial improvements in health
indicators toward achieving the Millennium Development Goals (MDGs), the National
Health Strategy suggests increasing per capita public expenditures in health from US$20 to at
least US$32, and the share of health expenditures on the budget from the current 9.3 percent
to 15 percent of the budget, as well as doubling external aid.13
Social Protection
30. Poor Zimbabweans lack a public safety net to protect their incomes and ensure
access to basic services, and have been relying mostly on humanitarian assistance for
pay for health, education, and food. While on the rise, government expenditure on social
protection and safety nets represents only a small proportion of spending in the social sectors
in Zimbabwe, amounting to 1.3 percent of GDP and 2.9 percent of the government budget in
2011. While additional resources are now being allocated to social protection, more than half
the resources are spent on administrative costs, notably under ―youth and indigenization‖
units (table 7). Public expenditures on safely nets (40 percent of the social protection budget,
and just 1.5 percent of total government expenditures) have mainly concentrated on
assistance to schools to pay for school fees of vulnerable children.
Table 7: Expenditures in Social Protection (Percent of 2011 Sector Budget)
12
Ministry of Health and Child Welfare (2009). 13
In the 2001 Abuja Declaration for Financing Communicable Diseases, governments pledged that 15 percent
of their annual budget should go toward health.
32
All Areas 35.8 13.6 49.2 1.5 - 79,905,000
Administration - Youth and Indigenization 25.8 2.7 11.5 0.1 - 40.1
Administration - Women and Community Development 3.8 1.8 2.6 0.4 - 8.6
Administration - Labour and Social Services 0.4 1.3 0.2 0.0 - 1.9
Vocational Training Centres 2.5 2.8 - 0.6 - 5.9
Social Services 2.1 3.2 34.8 0.3 - 40.4
Basic Education Assistance Module 16.3
Harmonised Cash Transfer 7.5
Food Deficit Mitigation Strategy 3.8
Others 7.3
Labour Administration 1.2 1.8 0.2 0.0 - 3.2
Areas
Recurrent Expenditures Capital ExpendituresTotal
ExpendituresEmployment costsGoods and
Services
Transfers and
Programmes
Fixed capital
assets
Capital
Transfers
Source: Ministry of Finance (2010).
Note: Includes Ministry of Labor and Social Services; Ministry of Women's Affairs, Gender and Community
Development; and Ministry of Youth, Indigenization and Empowerment.
31. The main public intervention on safety nets is the Basic Education Assistance
Module (BEAM). BEAM provides assistance for tuition fees, levies, and examination fees
to orphans and vulnerable children (OVC) in 61 districts of the country. It targets primary
and secondary school-age OVCs (around 25 percent of school enrollment) who have never
been to school, have dropped out of school, or are likely to drop out due to lack of funds.
Assistance is restricted to cover school fees and levies through block grants that are directly
transferred to schools, rather than cash transfers to individuals. BEAM has become the most
important social assistance program in terms of funding and number of beneficiaries. In
recent years, the government has concentrated on targeting secondary school beneficiaries for
support with its own resources, and leaving primary school beneficiaries for donor support.
In 2010, the government allocated US$15 million (two-thirds of all public resources
financing safety nets) to cover educational expenses of 243,000 secondary school OVCs,
complemented with funding from a pool of donors (managed by UNICEF) that provided
additional funding for 560,000 primary school OVCs through a US$20 million grant. For
2011, the government has reduced its budgetary allocation to BEAM to US$13 million.
32. Other beneficiaries and resources allocated to public assistance are made up of a
number of programs with low coverage. Public support in other social assistance
interventions targets mainly children, the elderly, families in distress, disabled persons, and
specific institutions supporting vulnerable persons. However, these interventions have low
coverage, account for a small percentage share of the total beneficiaries of public safety nets
(less than 3 percent of the total), but absorb a much larger share of the public resources (more
than half the government budget for safety nets). The bulk of the funds allocated to these
programs cover only administrative costs.
33. Government expenditure on social safety nets represents only a small proportion
of total spending on welfare programs within Zimbabwe, which are driven mostly by
NGOs and donors. Given the weak state of public social service delivery, donors and NGOs
have taken the lead in financing the sector since the onset of the economic crisis, through the
provision of food and agricultural inputs, food, medicine, and resources to pay for school
33
fees. For instance, in 2006 the World Food Program was running a US$151 million budget,
four to five times the estimated total value of government schemes then, and overall donor
contribution to social protection and food security programs reached US$230 million that
year.14
In 2010, the government expected donor assistance in social protection and food
security to reach US$85 million, mainly on food aid, and assistance to OVCs through the
Basic Education Assistance Module (BEAM) and other interventions, of which just US$11
million was made available in the first semester of 2010 (mostly for OVCs assistance), given
delays in transfer of donor funding commitments (table 8). A more coherent strategy for
donor support is needed, including coordination of efforts. While increasing government and
donor safety net expenditures as a share of GDP will be critical to boost human development
indicators, the scarce resources allocated need to be properly targeted and more efficiently
applied to achieve humanitarian goals.
Table 8: Expected Donor Assistance in Social Protection and Food Security, 2010 Basic Education Assistance Module 19,649,800
Food Aid 18,000,000
Integrated Humanitarian Relief 15,600,000
Orphans and vulnerable children 15,000,000
Public Works Programs 7,650,000
Social Safety Nets and Child Protection 7,222,496
Provision of Agriculture Extension Services 1,000,000
National Youth Capacity for Leadership 348,000
Gender Equity 300,000
84,770,296 Source: Ministry of Finance.
III. Challenges in the Education Sector
34. Zimbabwe’s recent achievements in delivering education to the majority of the
population are threatened. Thanks to investments in education in the last three decades,
Zimbabwe is now one of the most literate countries in Sub-Saharan Africa. Literacy rates are
almost universal; 90 percent of children between 6 and 12 years old attend primary school,
and almost half of youngsters between 13 and 18 years old are enrolled in secondary
education. Long-term investments in education are reflected in the proportion of adults (22–
65 years old) with complete primary education, which increased from 74 percent in 2001 to
83 percent in 2007 (figure 8).
35. The negative effects of the economic and political crisis were particularly strong
in the education sector. Budget cuts reduced the capacities of ministries with competence in
the education sector, the Ministry of Education, Sports, Arts, and Culture (MOESAC) and
the Ministry of Higher and Tertiary Education (MHTE) to plan, implement policies, and
monitor the education system as a whole. The crisis spread to schools, where the shortage of
teaching and learning materials was severe and pervasive. Staff salaries dropped
14
World Bank (2007).
34
significantly, infrastructure deteriorated, and teacher absenteeism became the norm. User
fees dramatically increased as schools sought to compensate for budget cuts, with a
disproportionately adverse impact on students from poorer households. School dropout rates
rose significantly. Despite these challenges, efforts from government, parents, and other
stakeholders prevented the system from collapsing completely. This situation is encouraging
since it suggests that the system found ways to cope with the crisis, and that if government
funding resumes, Zimbabwe has a good chance to return to the pre-crisis state.
Figure 8: Educational Level of Adults (22–65 years old), 2001–07
0
10
20
30
40
50
60
No
ed
uc
ati
on
Pri
ma
ry -
inc
om
ple
ted
Pri
ma
ry -
co
mp
lete
d
Se
co
nd
ary
-in
co
mp
lete
d
Se
co
nd
ary
-c
om
ple
ted
Te
rtia
ry
2001
2007-8
Source: World Bank staff calculations based on ICES 2001 and ICES 2007–08.
36. The education system in Zimbabwe consists of primary, secondary, and tertiary
levels. The official age of entry in the primary cycle is six years, and it runs for seven years
from Grade 1 to Grade 7.15
Before entering Grade 1, students may enroll in early childhood
education and preschool. Primary education is compulsory and students are given automatic
promotion from one grade to the next. Students are tested at the end of Grade 7, although
their admission to secondary education is not necessarily affected by their performance in the
exam. The official age of entry for secondary education is 13 years; it starts in Form 1.
Secondary education comprises a four-year Ordinary level cycle and a two-year Advanced
level. The students must sit for the Zimbabwe General Certificate of Education Ordinary
Level examination at the end of the first four-year cycle and on passing may proceed to
Advanced level or go on to further education at teachers training colleges or polytechnics.
Students’ performance in the Ordinary level examination determines their progression to the
Advanced level, admission to which is based on merit and the selection criteria set by
schools. Tertiary education in Zimbabwe covers all universities, technical colleges,
polytechnics, teacher training colleges and other vocational skills centers. The curriculum in
primary and secondary education is planned by the Ministry of Education, Sports, Arts and
Culture. The Ministry of Higher and Tertiary Education supervises the provision of tertiary
education.
15
World Bank (2007).
35
37. Primary school enrollment declined between 2005 and 2007, but has recovered
slightly since then. After independence, Zimbabwe made tremendous progress in extending
primary education to all segments of the society and came close to achieving the goal of
universal primary education. High retention rates and accessibility resulted in a rising net
enrollment rate that increased from 82 percent in 1994 to 94 percent in 2004, while literacy
levels for 15–24 year-olds rose from 92 percent in 1992 to 98 percent in 2002.16
However,
these trends began to reverse with the onset of the economic crisis in 2005. According to
MOESAC, near 2.53 million students were enrolled in primary school in 2005 (figure 9). By
2007, at the peak of the crisis, this figure had declined to 2.41. Most of this decrease can be
attributed to the Midlands, Matabeleland South, and Mashonaland Central provinces, which
collectively recorded an enrollment decrease of 107,000 students between 2006 and 2007.
Primary school enrollment has increased slightly since then, to reach 2.47 million in 2009,
but it has still not recovered even its 2006 level. No gender disparities are registered in
primary education enrollment. Official enrollment rates in primary education (as a percentage
of school-age population) are not available, but it has been estimated to be close to 91
percent in 2009, down from 96 percent in 2006. The latest data for primary completion rates
also show a significant decline from 83 to 68 percent between 1996 and 2006.17
Dropout rates
are high, of 9.4 percent in 2004.
Figure 9: Primary and Secondary School Enrollment, 2002–09
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
2002
2003
2004
2005
2006
2007
2008
2009
Primary School Enrollment Secondary School Enrollment
Source: MOESAC.
38. Grade progression rates are low in primary education. Data show a general
decrease in both the number of enrolled students in subsequent grades and across groups of
students between 2006 and 2009 (figure 10). Under normal circumstances, the number of
students who entered Grade 1 in 2006 (439,000) would have progressed to Grade 2 in 2007,
and Grade 4 in 2009. However, of the original 2006 entry cohort, there were just 364,000
students in Grade 2 in 2007, 352,000 in Grade 3 in 2008, and 342,000 in Grade 4 in 2009.
16
World Bank (2007). 17
UNDP (2010).
36
Figure 10: Primary Enrollment by Grade and Year, 2006–09
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
450,000
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Special
2006
2007
2008
2009
Source: MOESAC.
Figure 11: Secondary Enrollment by Form and Year, 2006–09
0
50,000
100,000
150,000
200,000
250,000
Form I Form II Form III Form IV Lower VI Upper VI Special
2006
2007
2008
2009
Source: MOESAC.
39. In contrast, secondary education enrollment has declined steadily. Admission
into secondary school is automatic, although a universal examination at the end of primary
school is used by private schools as a selection mechanism for their pupils. In secondary
education, the decline in enrollment has been more dramatic and steady. From 2001 to 2006,
secondary education enrollment declined from 51 to 46 percent.18
The number of students
enrolled at this level was 888,000 in 2006; by 2009, it was merely 783,000, a 12 percent
drop. Dropout rates for secondary education were estimated at 23.8 percent in 2004. This is
not surprising, since with the crisis many families may have found it difficult to sacrifice the
18
UNDP (2010).
37
potential income that a student could bring by working to supplement family income instead
of attending school. School dropouts are significantly larger at higher grades. For instance, of
the 208,200 students entering Form I in 2006, only 160,400 remained in Form IV in 2009
(figure 11). Slightly fewer women are attending secondary education (49 percent), though
this ratio diminishes to 35 percent for upper secondary.
40. The decrease in enrollment in secondary education can also be attributed to the
decline in quality standards in public schools, which may have created incentives for
some students to avoid the official school system. In urban areas, there has been a rapid
emergence of private schools, especially since 2008. Some teachers, because of poor
remuneration and working conditions in the public system, have joined forces with
entrepreneurs to offer classes in ―learning outlets‖ housed in converted churches, halls, and
private residences. Although data about the extent of this problem is not available, it is
expected that unofficial schools had the net effect of decreasing enrollment in public schools.
41. Most primary and secondary students attend public schools. There are around
4,913 established primary schools in Zimbabwe, and 1,797 secondary schools, with an
average size of 503 students per primary school and 436 students per secondary school. In
parallel, there are a number of ―satellite schools‖ that were established following the land
reform program in 2000 to cater to children who moved with their parents from established
areas to resettlement areas. Most primary schools students in Zimbabwe attend public
(district and central government) schools, which accounted for 85 percent of total primary
and secondary enrollment in 2007.19
Parents have the option of sending their children to a
private boarding school, a government boarding school, or a day school. Families have
increasingly opted for private education: in 2007, 7 percent of primary school students and 6
percent of secondary school students were attending private schools, up from 4 percent in
both in 2001 (figure 12). In Harare, primary private school coverage has expanded the most,
from 1 percent in 2001 to 18 percent in 2007 (private secondary education also expanded
from 6 to 10 percent over the same period). The rest of the students attend church schools.
Most students attend day schools for reasons of cost.
42. Part of the explanation for stagnant and declining enrollment levels is that many
students drop out since their families cannot afford to cover school fees and levies. In
light of the declining government resource allocation to cover school operational costs and
salaries for teachers, schools have been forced to rely heavily on student fees and levies to
retain teachers and continue operations. Between 2001 and 2007, the proportion of primary
school children with school fee waivers declined dramatically, from 50 to 30 percent, and for
secondary school children from 46 to 25 percent.20
Examination fees and levy waivers were
also eliminated by 2007. Issues surrounding the collection and administration of levies have
in some cases strained teacher-parent relationships. The requirement to pay fees and levies
has been a serious obstacle to enrollment and completion for millions of children from poor
economic backgrounds. While government policy stipulates that students cannot be excluded
from schools for nonpayment of tuition fees, anecdotal evidence suggests that many of them,
while attending, are not being allowed to sit in many of the classes or take final
19
ICES 2007–08. 20
ICES 2001; ICES 2007–08.
38
examinations. The cost of books, uniforms (at the primary level, all students are required to
wear school uniforms, which can cost between US$15 and US$25 in public schools), and
other associated expenses such as food and transportation typically prevent poor children
from remaining in school even if they are enrolled. For instance, during the food shortages in
2008, some boarding schools required students to bring food to school to supplement their
tuition fees. Because of economic hardships, some parents transferred students from urban to
rural areas where the costs are lower, while others are removing them from school altogether.
Data for 2007 show that 71 percent of children who drop out of primary school cited
financial constraints as the main cause, as did 48 percent of dropouts from secondary
school.21
Figure 12: Primary Enrollment in Private Education, 2001–07
0
2
4
6
8
10
12
14
16
18
20
Bula
way
o
Man
ical
and
Mas
hona
land
ce
ntra
l
Mas
hona
land
ea
st
Mas
hona
land
w
est
Mat
abel
e N
orth
Mat
abee
So
uth
Mid
land
s
Mas
ving
o
Har
are
Zim
babw
e
%
2001
2007-8
Source: World Bank staff calculations based on ICES 2001 and ICES 2007–08.
43. The pupil-to-teacher ratio has been on the rise and is of a concern in primary
education, but less in secondary education. Fuelled in part by low remuneration and poor
working conditions in many schools, the number of teachers employed declined in parallel
with the decline in student enrollment. There were 62,000 primary school teachers and
32,000 secondary school teachers in 2009, significantly fewer than in 1966 (66,000 and
36,000, respectively) . Most primary school teachers hold a diploma in teaching (at least a
secondary education degree), although a number of untrained and temporary teachers are
employed, particularly in rural schools in remote regions, because trained teachers tend to be
unwilling to serve in such locations. MOESAC has particularly identified critical shortages in
mathematics and science teachers. The percentage of primary school female teachers in
Zimbabwe is slightly above 50 percent, but in Bulawayo and Harare the percentage of female
teachers is close to 80 percent. In contrast, 56 percent of secondary school teachers are male.
. While in secondary education, the pupil-to-teacher ratio remained constant at 24 students
per teacher between 2006 and 2009, the ratio has increased in primary education, from 37.7
to 40 students per teacher. Both ratios are close to average African standards; however, the
21
ICES 2007–08.
39
ratio for primary education is significantly higher than the ratio in the southern part of the
region. South Africa and Botswana, for instance, have 31 and 25 students per teacher,
respectively (figures 13 and 14).
Figure 13: Figure Pupil-to-Teacher Ratio in Primary Education, Sub-Saharan Africa,
Average 2004–09
0
10
20
30
40
50
60
70
80
90
100
CA
RR
wa
nd
aC
on
go
, R
ep
.M
oza
mb
iqu
eZ
am
bia
Ch
ad
Gu
ine
a-B
issa
uE
thio
pia
Ta
nza
nia
Ma
liB
uru
nd
iM
ad
ag
asc
ar
Ug
an
da
Bu
rkin
a F
aso
Ca
me
roo
nE
ritr
ea
Be
nin
Gu
ine
aK
en
ya
Sie
rra
Le
on
eC
ote
d'I
vo
ire
Nig
er
Le
soth
oM
au
rita
nia
Zim
ba
bw
e (
20
09
)N
ige
ria
Se
ne
ga
lC
on
go
, D
em
. R
ep
.T
og
oG
am
bia
, T
he
Ga
bo
nS
om
ali
aS
ud
an
Co
mo
ros
Gh
an
aS
wa
zila
nd
So
uth
Afr
ica
Na
mib
iaS
ao
To
me
& P
pe
Eq
. G
uin
ea
Ca
pe
Ve
rde
Bo
tsw
an
aM
au
riti
us
Lib
eri
aS
ey
ch
ell
es
Sou
rce: World Development Indicators.
44. Low remuneration poses significant challenges to retaining teachers. Along with
the rest of the civil servants in Zimbabwe, teachers’ remuneration remains at low levels (at
around US$200 a month in 2010). There is a dire need to improve the working conditions for
teachers. Beyond salaries, these include provision of transportation, housing, loans, staff
development, and extra incentives for those posted to remote rural areas. High teacher
turnover affects student learning; when teachers are constantly replaced, new teachers must
take time to catch up on both the material being taught and learn about each student in the
class. A significant number of teachers migrated to neighboring countries, especially South
Africa, in search of better economic opportunities, contributing to the decline in the number
of teachers in Zimbabwe. To retain teachers, some schools are subsidizing teaching salaries,
depending on their available resources. Although these supplements have helped retain
teachers in some schools, they have exacerbated inequalities between schools that can afford
higher supplements compared to their peers with students from largely poor socioeconomic
backgrounds. Similarly, reliance on levies has also weakened the general social standing of
teachers, who now have to depend on stipends from parents. It has been reported that the
practice of after-school tutoring to supplement incomes is becoming more prevalent.
Although precise numbers are unavailable, this practice is confined mainly to students in the
higher grades of primary (Grades 6 and 7) and upper secondary schools.
40
Figure 14: Pupil-to-Teacher Ratio in Secondary Education, Sub-Saharan Africa.
Average 2004–09
0
10
20
30
40
50
60
70
80
CA
R
Eri
tre
a
Eth
iop
ia
Gu
ine
a-B
issa
u
To
go
Gu
ine
a
Nig
eri
a
Mo
zam
biq
ue
Ch
ad
Co
ng
o,
Re
p.
So
uth
Afr
ica
Bu
rk
ina
Fa
so
Nig
er
Ma
urit
an
ia
Ke
ny
a
Se
ne
ga
l
Bu
run
di
Na
mib
ia
Ma
da
ga
sca
r
Rw
an
da
Zim
ba
bw
e (
20
09
)
Be
nin
Sie
rra
Le
on
e
Ma
li
Ga
mb
ia,
Th
e
Ca
pe
Ve
rd
e
Za
mb
ia
Sa
o T
om
e &
Pp
e
Su
da
n
So
ma
lia
Ug
an
da
Gh
an
a
Sw
azil
an
d
Ma
urit
ius
Le
soth
o
Ca
me
roo
n
Co
ng
o,
De
m.
Re
p.
Bo
tsw
an
a
Co
mo
ros
Se
ych
elle
s
Lib
eri
a
Source: World Development Indicators.
45. Teacher absenteeism is the norm, as a consequence of low remuneration and
lack of capacity to monitor. Though the situation has improved since macroeconomic
stabilization, a consequence of low pay is that many teachers are not working the required
hours and supplement their incomes with alternative activities. Periodic strikes by teachers to
demand higher salaries also add to a general tough learning environment for students. While
data on attendance rates are not available, teacher and student absenteeism is said to have
increased lately (for example, during the election period) due to political instability, and lack
of basic foodstuffs in some provinces. During the hyperinflationary period, some students
and teachers left school to seek basic commodities such as bread. It has been estimated that
around 25 percent of teachers currently in place are temporary or unqualified. The Ministry
of Education, Sports, Arts and Culture does not currently have a supervision budget and
hence cannot control the time or quality of education delivered. Monitoring the system has
been a major challenge, given the serious lack of resources: no transportation and, in the few
cases where cars are available, no fuel or funds for maintenance.
46. A shortage of pedagogic materials and books in the classroom has also affected
educational quality. Teachers have frequently complained about the lack of basic pedagogic
materials in the classrooms, and anecdotal evidence suggests that sometimes they pay for
materials out of their own pocket. Government per capita grants are supposed to provide for
these expenditures, but the amount is often too low and arrives late in the academic year.
Widespread shortages in the provision of books have resulted in one book being shared by
more than 20 students in some schools (data for 2004). However, recent efforts, mainly from
donors through the ETF, aim for a large injection of primary textbooks to achieve a 1 pupil to
1 textbook ratio.
41
47. School infrastructure is severely deteriorated. Physical infrastructure has
deteriorated, and many schools are documented to be unsafe for children, with little or no
furniture. Just half of primary and secondary schools have blair toilets pit latrines, and barely
45 percent have water closets. A 2009 national study suggested that just 37 percent of
primary school classrooms can be classified as adequate in terms of infrastructure, with 37
percent in need of minor repairs, and 26 percent in need of major repairs. For secondary
schools, 45 percent needed minor repairs, and 19 percent major repairs.22
Moreover,
household survey data show a significant increase from 2001 to 2007 in the average distance
that children must travel to arrive at primary school facilities, from an average of 2.4
kilometers to 3.6 kilometers. These data highlight the challenge in transport costs that may
partially explain the slowdown in primary enrollment in recent years.23
A school facility
assessment is needed to evaluate the state of school infrastructure.
48. Poor educational quality is reflected in low grades and the low proportion of
students passing final examinations. Poor examination results suggest that the combined
effect of high pupil ratios in schools, teacher absenteeism, and lack of teaching and learning
materials had an adverse impact on the quality of education. Of the students who sat for
Grade 7 examinations, less than half passed all four subjects from 2006 to 2010. The national
Grade 7 pass rates between 2006 and 2009 ranged from a low of 20.1 percent in 2009 to a
high of 43.3 percent in 2007 (table 9). Of the number of students who passed all four subjects
at Grade 7, female students consistently outperformed males (with a pass rate 6.5 percent
higher than males). In secondary education, the pass rates at Ordinary level have more or less
oscillated at 20 percent between 2006 and 2009 for students who registered for five or more
subjects. At Advanced level, the pass rates for students who registered for two or more
subjects averaged 75 percent between 2007 and 2009. Males tend to have higher pass rates in
secondary school than females. That a much higher proportion of students at Advanced level
sat for the required minimum subjects compared to Ordinary Level suggest that a greater
proportion of students who proceed to Advanced level had some ability to pay for
examinations. Partly to address deteriorating quality issues in public education, private
tutoring has become widespread, especially in urban areas, with implications for equity.
Anecdotal evidence suggests that some teachers in the public school system encourage
students to come for private classes to cover other academic material for an extra fee.
Table 9: National Grade 7 Pass Rates for Primary School, 2006–09
YearGrade 7
Enrollment
Candidates
Examined
Number Passing
4 Subjects*
National Pass
Rates (%)
2006 298,204 273,183 105,174 38.5
2007 288,923 278,551 120,644 43.4
2008 296,467 259,233 78,366 30.2
2009 300,915 272,397 54,769 20.1 Source: MOESAC and ZIMSEC. Note: The highest score for Grade 7 is a 1 and the lowest is a 9. A pass is any score from 1 to 6. To pass four
subjects, students should get a combination of any scores that add up to no more than 24 in 4 subjects:
Mathematics, English, Local Language (Shona or Ndebele), and General Paper All candidates were tested in all
four subjects.
22
Chakanyuka, Chung, and Stevenson (2009). 23
ICES 2001; ICES 2007–08.
42
49. Overall enrollment in higher education has increased, even during the
hyperinflationary period. Enrollment in higher education increased from 72,000 students in
2007 to 87,300 in 2009. However, the evolution has been different for different careers. For
instance, enrollment in teacher training colleges (TTCs) declined throughout the period, from
17,900 students in 2007 to 13,600 in 2009, highlighting the challenges that the country will
face in overcoming teacher shortages in the years to come (table 10).24
In contrast, overall
university enrollment increased sharply from 40,900 in 2007 to 59,300 students in 2009
(table 11), mostly in the National University of Science and Technology, the Midlands State
University, and the Great Zimbabwe University.25
The increased enrollment in state
universities in 2008, at the height of hyperinflation, suggests that universities may have
become more attractive in part due to cost, since some students could acquire foreign
currency and use black market exchange rates to pay for up to a whole year for very little
money. Finally, enrollment in polytechnics also increased between 2007 and 2009, from
13,200 to 14,300 (table 12).
50. Gender inequalities in tertiary enrollment are of a concern, particularly in
university education. Gender parity in higher education is of a great concern because of its
implications for women’s ability to participate in the social, technological, and economic
development of the country. While the percentage of female students enrolled in teachers
colleges has consistently surpassed that of males, the percentage of women in universities
and polytechnics has remained at 40 percent (figure 15).
Table 10: Total Enrollment in Teachers Training Colleges, 2007–09
24
Zimbabwe has 14 teacher training colleges, 11 of which are primary teachers colleges and 3 of which are
state secondary teacher's colleges. Belvedere, Bondolfi, Hillside, Morgenster, Mutare, and Nyadireare private
primary teachers colleges, while the rest are state colleges. TTCs require a minimum of five Ordinary levels,
including English, Science and Mathematics, to admit students who want to teach at the primary level. Students
who study in conventional colleges train for three years. Secondary school teachers should have degrees,
diplomas, or certificates in education. However, some of the teachers in secondary schools are untrained. 25
Zimbabwe currently has seven public universities, four church-related universities, and a women's university.
Students who cannot attend residential university programs can also earn degrees through correspondence
through the Zimbabwe Open University, and other regional and international institutions affiliated with local
private institutions.
43
Source: MHTE.
Table 11: Total Enrollment in Universities, 2007–09
Source: MHTE.
51. Graduation rates are on the rise in universities. Between 2007 and 2009, a total of
79,300 students graduated from Zimbabwe's higher and tertiary institutions: 17,600 from the
14 teachers colleges; 47,300 from the 13 universities; and 14,400 from 7 polytechnics. But a
breakdown of graduations by types of institutions indicates that while universities saw an
overall year-to-year increase in the number of students graduating, both TTCs and
polytechnics witnessed a slight decline between 2007 and 2009 (table 13).
Table 12: Total Enrollment in Polytechnics, 2007–09
College/Year 2007 2008 2009
Belvedere 1447 1002 1220
Bondolfi 843 683 311 J. M. Nkomo Polytechnic 2263 1973 1973
Hillside 985 816 801
Madziwa 431 487 363
Marymount 1476 1209 1209 Masvingo 1087 1310 1310 Mkoba 1148 1447 1041 Morgan ZINTEC 1519 1353 1038 Morgenster 914 914 628 Mutare 1364 1131 1231 Nyadire 1137 641 431 Seke 1355 1236 1004 UCE 1899 1899 1007
Total 17868 16101 13567
Institution 2007 2008 2009
Africa 1284 1391 1538 Bindura 1091 1838 1828 Catholic 129 143 143 Chinhoyi 3287 3287 2176 Great Zimbabwe 2655 2655 6718 Harare Institute of Technology 141 343 343 Lupane 0 78 101 Midlands 2655 10887 10887 National University of Science and Technology 1993 6044 4924 Women's University of Africa 524 1455 1652 Solusi University 1877 1875 1875 Zimbabwe Open University 13808 11441 14631 University of Zimbabwe 11484 17816 12450
Total 40928 59253 59266
44
Source: MHTE.
Figure 15: Percentage of Female Students Enrolled at the Tertiary Level, 2007–09
0
10
20
30
40
50
60
70
2007 2008 2009
Fem
ale
Stu
de
nts
(%
age
)
Universities
Teachers Colleges
Polytechnics
Source: MHTE.
Table 13: Graduation Rates in Higher and Tertiary Institutions, 2007–09
Source: MHTE.
52. The economic crisis has impacted the human resource capacity of most higher
education and technical institutions. There are shortages of teaching staff in all higher
education and technical institutions. The number of filled positions is significantly lower that
established positions across all types of institutions (TTCs, polytechnics, and universities).
Vacancy rates are 2.2 percent in TTCs, and 31.3 percent in polytechnics. While no
consolidated information on teaching staff at universities is available, data from the
2007 2008 2009 Total
TTCs 6,063 5,845 5,674 17,582
Universities 12,353 14,211 20,763 47,327
Polytechnics 4,849 4,816 4,763 14,428
Total 23,265 24,872 31,200 79,337
45
University of Zimbabwe, the National University of Science and Technology, and the
Chinhory University of Technology confirm a significant decline in staffing. Training
materials, which are an essential part of the core mission of tertiary institutions, are also
significantly underfunded.
53. The economic crisis eroded some of the gains made in the development of
tertiary education infrastructure over the last decade. Government cuts in educational
expenditure negatively impacted the construction of new projects and the refurbishment of
older buildings in public universities. Many buildings are incomplete, and expenditure on
repair and maintenance has decreased in recent years. Tertiary institutions are now
distributing their resources just to make ends meet, which negatively impacts infrastructure
development.
IV. Challenges in the Health Sector
54. The great gains in health in Zimbabwe since independence were lost after 2000.
Before the onset of the economic and political crisis in the late 1990s, Zimbabwe had one of
the best health systems in Africa, with a well-developed infrastructure up to village level, as
well as an elaborate network of health facilities. The health system had well-functioning
preventive care and curative care aspects that were supported by a highly decentralized
management system. However, these gains began to unravel during the economic and
political crisis, with increased malnutrition of children, and higher mortality rates among
adults. The spread of HIV/AIDS also induced a decline in life expectancy at birth, falling
from 62 years in 1994 to 43 years in 2005 (figure 16). As in neighboring countries such as
Zambia, much of the decrease in life expectancy at birth can be ascribed to the HIV/AIDS
epidemic, with the highest impact reached in 2002.26
55. Health indicators have severely deteriorated in the course of the last decade.
Among the main causes of illness and death in Zimbabwe are HIV/AIDS, tuberculosis,
diarrhea, childhood illness, malaria, malnutrition, and reproductive health and pregnancy-
related conditions. Although some indicators related to HIV and malaria incidence have
recovered since 2008, the crisis has increased infant and maternal mortality levels, as well as
worsened most nutrition indicators. Moreover, despite some recent progress in reversing
trends, Zimbabweans continue to die from easily preventable and treatable conditions. These
trends are indicative of a broken health system with decreasing performance over time.
Consequently, the country is off track in most of its health targets, including the Millennium
Development Goals (MDG) targets (table 14).27
Figure 16: Life Expectancy at Birth and GDP per Capita (constant 2000 US$)
26
Manshande (2010). 27
UNDP (2010).
46
Source: Manshande (2010).
Table 14: Progress Toward Selected Health-related MDGs
Indicator 1999 2005 2009 2015
MDG
target Infant mortality rate (per 1000 live births) 65 60 60 22
Under-five mortality rate (per 1000 live births) 102 82 86 26
Stunting in children under 5 (percentage) 27 29 28 7
Maternal mortality ratio (per 100,000 population) 578 555 725 145
Skilled attendance at delivery (percentage) 73 69 60 100
HIV and AIDS prevalence (adults aged 15–49) 28 18 14 9
Adult ART (anti-retroviral therapy) coverage 40 100
Pediatric ART coverage 57 100
TB (tuberculosis) incidence (notifications per
100,000 population)
355 1047 762 70
Malaria incidence (cases per 1000 population) 136 102 81 62
Source: MOHCW.
56. Infant mortality remains high and far from MDG targets. While Zimbabwe had
infant and under-five mortality rates much lower than the Sub-Saharan Africa average in the
1980s, these rates got worse in the mid-1990s, unlike the SSA trend, but improved later, in
parallel with the regional trend. Infant mortality remained at 60 per 1,000 live births between
2006 and 2009 (figure 17). On the contrary, the under-five year mortality rate has worsened,
from 82 per 1,000 live births in 2006 to 86 per 1,000 live births in 2009. Children who live in
rural areas and those in the poorest 20 percent of the population are the most vulnerable. The
infant mortality rate is 0.4 percent higher in rural areas compared to urban areas, while the
under-five mortality rate is 1.4 percent higher in rural areas. The increase in child mortality
in the last decade is a consequence of a declining trend of coverage of key child health
47
interventions, particularly for the poor. The MDG target for under-five mortality, at 26 per
1,000 live births by 2015, will be almost impossible to reach.
Figure 17: Trends in Infant and Under-Five Mortality Indicators
0
20
40
60
80
100
120
1999 2005 2009 2015
Pe
r 1
00
0 li
ve b
irth
s
Infant Mortality Rate
Under Five Mortality Rate
MDG target
Source: MIMS 2009; World Development Indicators.
57. The main causes of child deaths in Zimbabwe are preventable and/or treatable
with known, simple, low-cost, and effective interventions. Information on causes of infant
and child deaths is available only at the hospital level, and not for other health centers. The
first cause of infant and child mortality in hospitals is acute respiratory infections (ARIs)
(figure 18).28
The second cause is perinatal circumstances, indicating poor conditions
surrounding birth, even when skilled attendance was available. Preterm birth, birth asphyxia,
and unexplained intrauterine death accounted for 77 percent of the causes of perinatal deaths,
while multiple pregnancies, maternal hypertension, and infection contributed to another 11.5
percent of the cases. Most of these infant and child mortality causes can be reduced through
adequate implementation of proven, effective interventions. Part of the relative progress
made in terms of reduction of child mortality is through treatment of ARIs, which have fallen
significantly between 1999 and 2006. Similarly, diarrhea is a common childhood infection
that, if untreated, can increase malnutrition and contribute to increased morbidity and
mortality. Fortunately, the diarrhea prevalence rate decreased in children under five from 26
percent in 1988 to 16 percent in 2006 and 11 percent in 2009, mostly among the 12–23–
month-old children (19 percent) (figure 19). But this progress may halt in the future in light
of the decline in the percentage of population with access to improved water, from 80 to 73
percent between 2006 and 2009.29
Lack of drugs in health facilities, and increase in costs to
reach or attend clinics and buy medicines, are key factors in limiting progress in reducing
infant and child mortality.
Figure 18: Principal Causes of In-Patient Mortality at the Hospital Level (excluding
Central Hospitals) for Children under Five in 2006 (Number of Deaths)
28
MOHCW (2006). 29
ICES 2007–08.
48
0100200300400500600700800900
1000
AR
I (L
ow
er
Trac
t)
Ce
rtai
n C
on
diti
ons
in
Pe
rin
atal
Per
iod
Inte
stin
al In
fect
ion
s
Nu
trit
ion
al
De
fici
en
cie
s
Ma
lari
a
Skin
an
d S
ub
cuta
neou
s
AR
I (U
pp
er
Trac
t)
Sig
ns,
Sym
pto
ms
and
Il
l-d
efi
ned
Co
ndit
ion
s
Oth
er
Vir
al a
nd
R
esp
irat
ory
Dis
eas
es
Oth
er
End
ocr
ine
and
M
eta
bo
lic
Dis
ea
ses
Pu
lmo
nar
y TB
1-4 years
<1 year
Source: Manshande (2010).
Figure 19: Diarrhea Prevalence for Children under Five
Source: Manshande (2010).
58. Child vaccinations and immunizations have severely declined in recent years.
Child vaccination is one of the most cost-effective interventions to ensure child health. In
Zimbabwe, it has been mainly implemented through the Expanded Program on Immunization
(EPI), cofounded by the government and UNICEF, though it has recently been challenged by
the decline in financing of drugs, transport systems, and loss of skilled personnel (village
health workers) to implement vaccinations and outreach services. As a consequence, the
coverage of measles vaccination has declined from 86 percent in 1994 to 77 percent in 2009.
Moreover, full-child immunization (against measles, tuberculosis, diphtheria, tetanus, and
49
polio) is low and has worsened in recent years. The deterioration has been dramatic in the
last decade: the percentage of children aged 12–23 months who had been fully immunized
before their first birthday was 49 percent in 2009, compared with 80 percent in 1994. On a
positive note, the proportion of children who had not received any vaccination before their
first birthday fell from 22 percent in 2006 to 7 percent in 2009. While supply side efforts are
commendable, it is probably also necessary, through demand side interventions, to ensure
that mothers fully understand the importance of the complete series of vaccinations to
guarantee the child’s good health.
59. The number of children who are malnourished, as measured by severe stunting,
increased between 1999 and 2009 in both rural and urban locations. Health, food, and
care are the immediate determinants of malnutrition. Children who are moderately and
mildly malnourished are 4.6 and 2.5 times respectively more likely to die than well-
nourished children.30
The prevalence of underweight children under five years of age has
oscillated between 13 and 17 percent in the 1990s and 2000s (figure 20). But stunting, which
is a measure of chronic food shortages, has increased in most provinces, particularly so in
Midlands and Harare, at rates that are alarming: 28 percent of children between 6–59 months
are currently stunted (the MDG target is 7 percent by 2015). The increased and persistent
stunting rate probably reflects both food shortages related to economic challenges to buy
protein-rich food and a tendency to feed children with low-nutrient starches, a possible zinc
deficiency, and the increasing unhygienic environment. Boys are significantly more
malnourished than girls, and children living in rural areas have higher rates of malnutrition
than those living in urban areas. Children in rural areas are significantly more likely to be
stunted and underweight, while the wasting levels are similar in rural and urban areas. rate of
exclusive breastfeeding is alarmingly low (at 26 percent in 2009); hence more than 50
percent of children are receiving complementary foods before they are 6 months old, against
the World Health Organization (WHO) prescription.31
Mixed feeding at such an early age has
negative implications for both growth and disease transmission. Also, WHO recommends
provision of Vitamin A supplements every four to six months to children 9 to 59 months old,
which is usually administered in Zimbabwe as part of the routine immunization services, and
during national immunization campaigns. In 2009, barely 23 percent of the children in that
age group were receiving Vitamin A (a marked decline from 47 percent in 20006). The
nutrition challenges facing the country have been further complicated by the high HIV/AIDS
prevalence rate, particularly among mothers and newborns, and an accumulation of a high
number of orphans. The role played of village health workers is key to monitor child feeding
practices and provide related education, and its revamping is an example of a low-cost
intervention that will surely have positive effects on child nutrition.
Figure 20: Nutritional Status of Children, 1994–2008
30
Pelletier (1994). 31
Manshande (2010).
50
0
5
10
15
20
25
30
35
1994 1999 2005 2008
Wasting
Stunting
Underweight
* Age range of children 1994, 1999 = 0-35 months; 2005 = 0-59 months; 2008 = 6-59 months
Source: Manshande (2010).
60. The maternal mortality rate has increased substantially in recent years. Maternal
mortality rates increased from 555 to 725 deaths per 100,000 between 2006 and 2009, and
are currently one of the highest in Sub-Saharan Africa and far from the MDG target of 145
per 100,000. The main causes of maternal mortality in Zimbabwe include: HIV- and AIDS-
related (26 percent), post partum hemorrhage (14 percent), hypertension (13 percent), and
puerperal sepsis (8 percent) (figure 21). In the case of Zimbabwe, the coverage of at least one
antenatal care (ANC) visit, important for improving the health of the mother and the
likelihood of survival of the infant, has declined from 94 percent in 2006 to 88 percent in
2009. Moreover, the proportion of women who received ANC for the recommended four or
more times during pregnancy is just 71 percent.32
Furthermore, there are indications that the
quality of the ANC provided during antenatal visits is deteriorating.33
Skilled birth attendance
is the single most important intervention to prevent maternal mortality, but has decreased in
recent years, from 73 percent in1999 to 69 percent in 2006, and further to 60 percent in 2009.
Assisted deliveries by a skilled birth attendant ensure prevention of mother-to-child HIV
transmission and provide basic emergency obstetric, and newborn care. Cases of home
delivery have generally been on the rise since 1999, in the context of economic hardships and
a weakened health delivery system. There is a stark difference between rural and urban areas;
51 percent of women in rural areas deliver babies at home, compared to 10 percent in urban
areas. The disruption in ambulance transport, the cost of other transport, the uncoordinated
burgeoning of user fees at first contact level, and the high fees at the hospital level, combined
32
The antenatal period provides an opportunity to reach pregnant women with a number of interventions,
including immunization against tetanus, management of anemia and pregnancy-induced hypertension,
preeclampsia screening, prevention and treatment of malaria, promotion of assisted delivery by a skilled health
care provider, and supply of information on family planning for spacing or limiting. WHO recommends that a
pregnant woman have at least four ANC visits, with the following minimum tests: (i) measurement of blood
pressure; (ii) testing of urine for proteinuria and bacteriuria; and (iii) blood tests to detect syphilis and severe
anemia. Ideally, routine weight and height measurement should also be undertaken to assess maternal
nutritional status 33
For instance, the percentages of women who had their weight measured and/or left a blood sample during the
visit decreased from 95 percent and 79 percent, respectively, in 1999 to 80 percent and 62 percent in 2009.
51
with the de facto suppression of fee exemption, all significantly hinder financial access to
health care for many impoverished women, particularly in rural areas. Cultural factors also
play a role: those belonging to the apostolic faith reject health care, relying on praying
instead.
Figure 21: Main Causes of Maternal Mortality, 2007
0
5
10
15
20
25
30A
IDS
de
fin
ing
cond
itio
ns
Po
stp
artu
m h
aem
orr
hag
e
Hyp
ert
en
sio
n/Ec
lam
psi
a
Pu
erp
era
l se
psi
s
Ab
ort
ion
co
mp
licat
ion
s
Mal
aria
Ob
stru
cte
d la
bou
r
Ecto
pic
pre
gnan
cy
Suic
ide
Car
dia
c d
ise
ase
An
tep
artu
m h
aem
orrh
age
Ru
ptu
red
ute
rus
An
aest
he
tic
rela
ted
Oth
er
cau
ses
%
Source: Manshande (2010).
61. Zimbabwe has a high modern contraceptive prevalence rate which is decreasing
fertility rates and population growth, a contrast with regional neighbors. Zimbabwe has
one of the highest modern contraceptive prevalence rates in Sub-Saharan Africa, and the rate
has continued to increase, from 43 percent in 1990 to 65 percent in 2009, mainly accounting
for use of the pill (as opposed to injectable and irreversible long-term methods). As a
consequence, adolescent birth rates, which should indicate the extent to which this vulnerable
group is protected, have decreased from 91 per 1,000 women aged 15–19 in 2001 to 64 in
2008. This is well below the SSA average of 116. Furthermore, the unmet need for
contraception is also fairly low compared to the regional average and has been stable at 13
percent. This has implications for fertility rates and projected population growth: the total
fertility rate (TFR) of 7.3 births per women in 1980 had fallen to 3.7 in 2009, as the
contraceptive prevalence rate steadily increased (figure 22).34
It appears that, contrarily to
most other Sub-Saharan African countries, Zimbabwe will go through a period with a
relatively stable number of dependants. This has important positive implications for social
sector programs.
Figure 22: Projections for Total Fertility Rate (TFR) and Population Growth
34
Manshande (2010).
52
0
1
2
3
4
5
6
7
8
19
50
19
55
19
60
19
65
19
70
19
75
19
80
19
85
19
90
19
95
20
00
20
05
20
10
20
15
20
20
20
25
20
30
20
35
20
40
20
45
%
TFR
Population Growth Rate
Source: Manshande (2010).
62. Zimbabwe has been severely affected by the HIV and AIDS epidemics, but the
spread began to reverse in the 2000s. The prevalence of HIV among the population aged
15–49 years is an important indicator of the spread of HIV/AIDS. Evidence from successive
surveys in Zimbabwe shows that the prevalence rate in this age group has decreased from an
astonishing 28 percent in 1999 to 18 percent in 2006 and to 14 percent in 2009. The decline
in HIV prevalence could be attributed to a combination of higher mortality rates, migration
of adults to neighboring countries, and a decline in HIV incidence due to behavior change. In
the context of the MDG target of halting and reversing the spread of HIV/AIDS by 2015, this
represents a success, especially since Zimbabwe is the first country in Southern Africa
showing a decline. Having said this, Zimbabwe still ranks among the top four countries in the
world, with the highest double-digit prevalence rate, and women are disproportionately
affected. Moreover, while the country is on a good path to reducing HIV/AIDS incidence, the
risks of losing ground are very high if no sustained financing is provided to minimize new
infections and strengthen HIV prevention.
63. Universal access to treatment for HIV/AIDS is far from being a reality. Anti-
retroviral therapy (ART) in 2009 had a national coverage of 40 percent for adults and 57
percent for children. Even if these coverage rates are fairly low in comparison to neighboring
countries, they present a substantial increase from previous coverage rates of children of 25
percent in 2007 and 39 percent in 2008. Generally, from the supply side perspective, funding
gaps have been a hindrance in terms of Zimbabwe achieving universal access to ART. On the
demand side, major obstacles for patient uptake of ART include lack of transport, costs,
availability of drugs, and stigma. Donors continue channeling substantial funds to fight the
epidemics. Donor support in 2005 was estimated to represent around US$72 per HIV-
infected person in Zimbabwe (in 2010 dollars).
64. Condom use has not improved significantly in recent years, but the number of
people with comprehensive knowledge about HIV and AIDS is increasing. It does not
53
appear as if the reduction in HIV prevalence can be attributed to increasing condom use,
since this indicator has been fairly stable. For the population aged 15–24, condom use for
men declined from 56 percent in 2000 to 52 percent in 2008. For women, the corresponding
figures were 11 percent to 9 percent, respectively, for the same years. The latest estimate
(from 2009) of the proportion of people aged 15–24 with comprehensive correct knowledge
of HIV/AIDS shows that 53 percent of the women aged 15–24 years had comprehensive
knowledge about HIV transmission, up from 44 percent in 2006. Thus, these and other
estimates give testimony to an encouraging trend of improved HIV/AIDS knowledge among
young people.
65. The incidence rate of malaria has been less of a concern since 2004. While
malaria remains a major public health problem in Zimbabwe, and it is a top ten cause of
infant and child morbidity and mortality, its incidence has steadily declined in the last five
years. Malaria rated declined from 154 cases per 1,000 population in 2004 to 81 cases in
2008 (figure 23). While malaria is endemic throughout Zimbabwe, there is an ecological
distribution of malaria, and the so-called ―malaria prone areas‖ represent now 45 of
Zimbabwe’s 89 districts. Progress has been made in preventive care: the proportion of
children under 5 sleeping under insecticide-treated bed nets has increased from 3 percent in
2006 to 17 percent in 2009. Household owning at least one bed net has also increased from 9
percent to 27 percent during the same time period. Finally, the proportion of children under 5
with fever who were treated with an anti-malarial drug has increased from 5 percent in 2006
to 14 percent in 2009, which is still at a very low level.
Figure 23: Malaria Incidence Rates per 1,000 Population
136 137
117
155 154
102108
95
81
68
0
20
40
60
80
100
120
140
160
180
2000 2001 2002 2003 2004 2005 2006 2007 2008 2010
Inci
de
nce
rat
e/1
00
0
Source: MOHCW.
66. Tuberculosis (TB) incidence has dramatically surged in the last decade, while
case detection rates and treatment rates have diminished. TB is among the top 10
diseases of public health importance in Zimbabwe and is indeed a leading cause of death
among adults. Once thought to be on the decline, TB rates have steadily increased in the last
54
decade. The incidence rate of TB, which mostly affects the 25–44 age groups, increased from
121 per 100,000 per year in 1990 to 762 in 2008. It is quite far from the MDG target of 70 by
2015. The proportion of tuberculosis cases detected (under all forms) declined from 60
percent in 2000 to 49 percent in 2005 and 39 percent in 2008. The trend in treatment
successes fell from 69 percent in 2000 to 60 percent in 2006. Zimbabwe’s TB control
program has been adversely affected by lack of adequate financial, human and material
resources.
67. Zimbabwe has experienced several cholera outbreaks since the 1990s, but these
have been alleviated by emergency approaches. In the most recent cholera outbreak,
between August 2008 and May 2009, there were a total of 98,424 reported cases and 4,276
deaths.35
This was an alarming rate, considering that cholera is an easily preventable disease.
The highest recorded cases were from the high density areas, particularly in Harare. These
high density areas are known to be greatly disadvantaged from the poor provision of water
and inefficient sewage services. Other locations affected included the border towns where
Zimbabweans crossing the border would prolong their stay before they finally crossed the
border. More recently, cholera epidemic cases have diminished thanks to national cholera
command centers that provide cholera kits at the district level and coordinate information and
communication. While some ground has been made to reverse the conditions that perpetuated
the cholera epidemic, there is still a huge gap regarding improvements to the sanitation and
water systems in some urban and rural areas. For instance, in rural areas coverage of
improved water and sanitation is 68 and 50 percent, respectively, much lower than in urban
areas.36
This makes the country vulnerable to another outbreak and presents the need for
prioritized financing, particularly through urban local authorities (local government) to
improve water and sanitation infrastructure. Also, the national health information system
faces challenges in ensuring communication of data concerning reported cases; this greatly
compromises efforts to contain the outbreak
68. The majority of the population seeks care in government health facilities, but
other service providers are important in Zimbabwe. Public health care in Zimbabwe is
delivered at four levels: central and specialized hospitals (―third referral level‖); provincial
and general hospitals (―second referral level‖); district and church hospitals (―first referral
level‖); rural health centers, rural hospitals, town clinics, and village health workers (―entry
level‖). A well-defined referral system exists, but it has grown longer and more expensive
since patients are referred from one level to the next without assurance that they will access
the proper service. In 2006, the Ministry of Health and Child Welfare was operating about
1,331 rural health centers, and 181 first level centers (church and district hospitals), which
provide referral and supervisory support to all centers and clinics in the district. However, the
ill often bypass lower levels of care because of user fee charges and shortages of staff and
drugs (table 15). The Ministry also manages 7 provincial hospital, and 14 central and
specialized hospitals, which handle the most complicated cases. Mission hospitals (126
clinics) and rural district councils (67 clinics) are the main service providers in rural areas.
The nonprofit sector also comprises faith-based organizations, which mainly operate in rural
areas. Household survey data for 2007 show that most people (50 percent) seek health care
35
UNDP (2010). 36
UNICEF (2010).
55
from public health facilities when feeling ill in the previous three days, followed by private
health facilities (10 percent), and traditional faith healers (4 percent), while more than one
third did not visit any facility at all (36 percent).37
Table 15: Registered Facilities (Including Mission Hospitals) Managed by the Ministry
of Health and Child Welfare, 2006 Provinces Rural
health
centers
District and
church
hospitals
Provincial
hospitals
Central and
specialized
hospitals
Total
facilities
Harare 45 0 0 7 52
Manicaland 253 36 1 0 290
Mashonaland Central 130 15 1 0 146
Mashonaland East 168 22 1 0 191
Mashonaland West 128 22 1 0 151
Matebeleland North 92 17 0 0 109
Matebeleland South 105 18 1 0 124
Midlands 206 28 1 0 235
Masvingo 170 23 1 0 194
Bulawayo 34 0 0 7 41
Total country 1331 181 7 14 1533
Source: MOHCW (2009).
69. Preventive services—such as antenatal care, childhood immunization, health
education, family planning, nutrition, and environmental health services—are provided
at the health center and district hospital levels with support from community health
workers, under the direction of a district health team. These teams are also responsible
for outreach activities, such as mobile immunization clinics and training and supervision of
village health workers.
70. The private for-profit sector has increased since the 1990s and constitutes a total
of 1,800 institutions. This sector includes for-profit hospitals, nursing homes, maternity
homes, industrial clinics and general practitioners, private laboratories, and imaging
facilities. The sector expanded rapidly in the 1990s. Today, it has a total of 1,803 institutions,
including national municipal clinics. Of these, the main categories of outlets include 779
medical consulting rooms, 134 dental surgeries and 126 industrial clinics. Furthermore, there
are about 261 private pharmacies in the country. Private for-profit institutions are mostly
found in urban areas (mainly in Harare, Bulawayo, and provincial capitals), and are
unaffordable for most of the poor.
71. The deterioration in health services can be traced to the lack of sufficient
availability of health workers. The health payroll increased by just 5 percent between 2005
and 2009, mostly due to the increase in nurses, who represent the bulk of the payroll, to reach
a total of 35,000 workers. This is not enough to cover a significant portion of the population.
Zimbabwe has a physician density of 0.2, a nurse density of 0.7, and an overall density of 1.2
health staff per 1,000 population. According to the WHO, in order to be able to achieve its
MDGs, Zimbabwe should achieve a health worker density of at least 2.5 per 1,000
37
World Bank staff calculations based on ICES 2007–08 data.
56
population. Significant shortages of medical and nursing staff (mainly of nurse midwives)
particularly in rural areas, and of drugs and medical supplies, are causing a decline in the
quality of health services. It is estimated that just 19 percent of villages (comprising 46
percent of the rural population) have active village health workers, due to the lack of training
programs in most districts and poor remuneration.38
Brain drain of medical staff to foreign
countries is reflected in the number of vacancies within the public services in Zimbabwe
though they have declined substantially compared with 2005 rates (figure 24). It has been
estimated that among larger countries in the world, Zimbabwe has the highest brain drain rate
of physicians (45 percent in 2004). Increasing the numbers of trained health professionals has
been one of the strategies to counteract the skills drain of physicians. But the high vacancy
rates for university teachers and tutors (up to 68 percent) have also caused disruptions in the
production of human resources for health. And if retention mechanisms are not put in place,
these new physicians are likely to migrate as well.
Figure 24: Vacancy Rates (Percentage of Established Positions)
at Government Health Care-Related Institutions
0
10
20
30
40
50
60
70
80
90
100
Do
cto
rs
Nu
rsin
g
Envi
ron
me
ntal
H
eal
th
Ph
arm
acy
Rad
iogr
aph
y
Ph
ysio
the
rap
y
Ort
ho
pae
dic
Ora
l he
alth
Lab
ora
tory
Re
sear
ch O
ffic
ers
%
2005
2006
2007
2008
Source: MOHCW.
72. A number of mitigation measures have been put in place to retain health
workers. Some of the strategies that are being used to improve the human resource situation
in Zimbabwe include: (i) reentry after resignation or retirement; (ii) two-year bonding of
newly graduated doctors, nurses, and pharmacists, (iii) introduction of innovative and generic
health cadres such as primary care counselors, X-ray operators, and other community health
staff better equipped to work in rural areas; and (iv) incentive programs funded by various
donors. Unfortunately, data on the impact of these different measures on retention,
motivation and performance are very limited. Donor-funded salary supplements seem to have
increased the number of health workers that report for duty, but anecdotal evidence suggests
38
MOHCW (2010).
57
that the same incentive schemes have caused tensions among health team and decreased
motivation of lower-level staff that are not included in the scheme. As mentioned, none of
the current salary incentive programs are tied to the performance of the health workers.
73. The availability of essential drugs has been challenging for many years, but
efforts from donors in recent years have improved access. The National Pharmaceutical
Company of Zimbabwe (NatPharm), a nonprofit organization, is the major supplier of
pharmaceuticals and medical operating through the public health system supplies in the
country. Medicines and other pharmaceutical supplies are sold to public health facilities on a
cost-recovery basis. NatPharm is the procurement agent for the health sector, with priority
being given to public health institutions, which are expected to procure from NatPharm in the
first instance. In an environment with declining allocation of government resources to the
health sector, the procurement and distribution of drugs and medical supplies has been
problematic for a number of years. During the years of hyperinflation years, NatPharm could
spend only 3 percent of its original budget on imported drugs, mainly due to the lack of
foreign currency, which almost depleted stocks of most medicines that are manufactured
abroad.39
The decline in government expenditure has been compensated for by donor
assistance in recent years, and some remarkable improvement in the availability of drugs at
the health facility survey has been noted. About 90 percent of medicines for primary health
care at clinic and district levels in 2009–10 were financed by development partners. The
Vital Medicines Support Program, a joint effort to deal with lack of essential drugs to tackle
communicable diseases, was launched by a number of donors to address the critical shortage
of drugs in 1,400 health centers and hospitals across the country. As a consequence, the
availability of essential drugs (―primary health care package‖) increased substantially
between 2008 and 2010. For instance, the number of health facilities in the program with at
least half of the selected essential drugs in stock increased from 44 percent to 91 percent;
more than 70 percent of the antibiotics in stock increased from 35 percent to 82 percent; and
at least half the cholera response commodities available in stock increased from 90 percent to
97 percent. Government still faces challenges in availing funds for drugs in provincial and
central hospitals, and for non communicable diseases.
74. Health medical equipment is lagging behind and is in serious need of repair. Most medical equipment and facilities have outlived their life spans and need replacement.
Lack of budget for district hospitals to pay contractors that service and repair machines have
led to a decline in services offered. In addition, a collapsed radio and telecommunications
system leads to patients being moved from one point to the next without prior knowledge of
whether the right services are available. To compound the situation, the breakdown in the
communication system is making it difficult for health facilities to share working equipment
and medicines. Supervision of health facilities and quality of services at all levels of the
system has been weakened by human resource, financing, logistical and other challenges.
Donors are making efforts to support the provision of critical medical equipment. For
instance, a large consignment of emergency obstetric care equipment was received from the
United Nations Population Fund (UNFPA) in 2007. In districts with external support from
Global Fund, new equipment has been procured and better services are being provided. This
39
MOHCW (2010).
58
has led to a variation in quality of services between districts with external support and those
without, and also between government, local authority, and faith-based facilities.
75. Health centers are not easily reached by the majority of rural population.
According to the Ministry of Health and Child Welfare, each rural health center is expected
to cover a population of 10,000 and no person should be more than 8 kilometers walking
distance from a health center. However, due to population displacement and dilapidated
infrastructure, in 2008, 23 percent of the population was living between 5 to 10 kilometers
from the nearest heath facility and 17 percent was living over 10 kilometers from it.40
The
average distance to a hospital clinic in rural areas was 7.9 kilometers in 2007, compared with
2.3 kilometers in urban areas.41
Lack of transport in the rural areas, where most roads are in
disrepair, is one of the major barriers to assistance in birth deliveries for mothers. To increase
physical access, a number of construction projects have been initiated since 2000. Yet health
centers have not kept pace with population expansion, and big gap continues to exist for
secondary care facilities in urban areas, combined with lack of ambulances even in district
hospitals. This situation has resulted in provincial and central hospitals being used as first
referral centers, leading to congestion and a decline in the quality of services offered.
Whenever funds have been made available, construction activities have been very slow,
resulting in some of the projects taking up to 10 years to complete. A number of projects
have come to a standstill as a result of inadequate funding, but also due to poor management
of contracts. Resuming these infrastructure projects should be a priority, since there are sunk
costs and returns would to be high for a marginal investment in them.
76. The number of people seeking care has been falling, not only because of
increased costs, but also because of a loss of confidence in the services provided, and
availability of health centers. The dollarization of the economy has impacted the cost of
health care. Moreover, a majority of the poor cannot access health services—which is
officially free at first contact level—due to various forms of formal and informal user fees
charged by health facilities. It has been estimated that the majority of the population (close to
60 percent) pays to access health care services, especially in urban areas, commercial
farming areas and mines.42
Household survey data for 2007 show that 40 percent of those
feeling ill were not visiting any public or private health facility, with 33 percent of them
claiming that they could not afford to do so (up from 25 percent in 2001).43
In rural areas,
people are paying user fees at the district and church hospitals level and also in most rural
health centers/clinics. High transportation costs, particularly for rural people, to reach a
health institution, increase the overall costs of seeking health care, such that people are
deterred from attending health care institutions. People tend to delay seeking health services
due to the cost, and when they come to health facilities, treatable conditions might have
worsened, especially for maternal cases. The government used issue fee waivers/vouchers
through Assisted Medical Treatment Orders (AMTOs) to indigent persons to facilitate access
to intermediate and tertiary health services, such as a provincial or national hospital or other
specialist facilities; however, this scheme is currently underfunded.
40
MOHCW (2010). 41
ICES 2007–08. 42
MOHCW (2010). 43
World Bank staff calculations based on ICES 2001 and 2007.
59
V. Challenges in the Social Protection Sector
77. After a decade of the socioeconomic crisis in Zimbabwe, the size of the
vulnerable population has surged, but at the same time most forms of Government
funded social protection for the poor have almost ceased. Formal employment has
declined following land reform and hyperinflation. Social insurance schemes (pensions,
health insurance) were wiped out and there is very little scope to enforce labor market
regulations. Publicly funded social assistance remains at a reduced rate, often under unclear
targeting mechanisms. The crisis left a large number of orphans and vulnerable children,
disabled, and elderly suffering from chronic illnesses without protection. Most of the
distribution of food aid during the height of the crisis was by NGOs and donors.
78. The crisis has left a large percentage of the population in poverty. While no
official poverty figures are available, the latest official figures show that the proportion of
extreme poor households (that could not meet basic food requirements) in Zimbabwe has
increased from 20 percent in 1995 to 48 percent in 2003.44
Extreme poverty increased more
in communal and resettlement areas, compared with urban areas. In the same period, the
proportion of moderately poor households (that could not meet total consumption
requirements) went from 42 percent in 1995 to 63 percent in 2003. Lack of recent data
collection on household livelihood post crisis prevents the analysis of poverty trends after
2003. But given the high cost of living of foodstuffs, combined with stagnant or falling
incomes and higher unemployment experienced after 2003, it is expected that these 2003
poverty rates has substantially raised in later years.
79. About 1 million children in Zimbabwe are orphans or vulnerable (OVCs). The
2003 Poverty Assessment Study Survey (PASS) estimated that 30 percent of all infants to 17-
year old children were considered as OVCs in Zimbabwe; 22.3 percent are orphans (with
one or both parents dead) and the rest are vulnerable (disabled, infected by HIV/AIDS,
destitute, abandoned, living on the streets, married, having chronically ill parents, and the
like). Data from the ICES 2007–08 show that the proportion of orphans rose slightly to 23
percent, with 5.8 percent with both parents dead. More recently, it has been estimated that
number of OVCs was 976,000 in 2009,45
down from 1,140,000 in 2004.46
The general
decrease of OVCs has been attributed to the introduction of anti-retroviral therapy (ART),
with subsequent reductions in infant mortality. About 70 percent of the orphans in Zimbabwe
are in that condition due to HIV and AIDS that affected their parents’ health. Most of them
being taken care of by extended family members (uncles, grandparents) or female-headed
households, adding an extra economic burden to those families. While OVCs are marginally
less likely to be enrolled in primary school than non-OVCs thanks to the Basic Education
Assistance Module (BEAM), UNICEF has estimated that OVCs were 30 percent less likely
to be accessing appropriate health care than non-OVCs.
44
PASS (2006) 45
MIMS (2009). 46
Government of Zimbabwe (2004).
60
80. Nearly 3 percent of the population is disabled. The latest Zimbabwe Population
Census available, from 2002, reports approximately 350,000 people with disabilities,
equivalent to 2.9 percent of the national population. This figure was further validated by the
Poverty Assessment Study Survey (PASS) of 2003, which showed that 3 percent of people
were disabled nationwide. Rural areas had a slightly higher prevalence of persons with
disabilities than urban areas. The main type of disability found at the national level in the
study was difficulty in moving, followed by difficulty in seeing. About 68 percent of disabled
persons were prevented from maintaining significant economic activity or going to school
due to their condition.
81. Zimbabweans are vulnerable to severe shocks that create food insecurity and
produce changes in household behaviors. During hyperinflation years, Zimbabwean
suffered high inflation and unemployment that had altered their eating, health-seeking, and
schooling behaviors. Not only economic shocks impact the daily livelihood of Zimbabweans;
natural disasters (such as recurrent droughts), epidemics, and political violence also affect
habits and negatively impact the well-being of the poorest segments of the population that
cannot count on insurance or other coping strategies. For instance, the World Food Program
has estimated that during the crisis more than half the surveyed households had sold assets to
buy food or pay for health care. The proportion of households that had consumed three meals
a day declined from 54 percent in 2006 to 23 percent in 2009, indicating that households may
reduce the number of meals as a coping strategy in the face of shocks.47
As of 2003, around
77 percent of the poor and almost 90 percent of the extreme poor were residing in rural
areas.48
Even when agriculture continues to be one of the important sources of livelihoods for
the majority of households, around 33 percent of households are still considered food
insecure.49
In rural areas, 97 percent of families were producing at least one type of crop for
consumption in 2009; however, cereal stocks were running short by at least 25 percent from
estimated requirements in that year.50
The government used to handle a large-scale Drought
Relief and Public Works Program (PWP) as a cash and food-for-work scheme, which
covered around 350,000–400,000 beneficiaries in 2004–05, but its coverage has been
reduced to minimum since the hyperinflation (figure 25). The concept of food sovereignty is
key in Zimbabwe, and includes the revival of food production within the country, in
particular of food that is nutritious and varied, and that progressively diminishes dependency
on imported and donated food—as has happened during the past few years.
Figure 25: Evolution of Beneficiaries of Public Works Programs, 2004–08
47
UNDP (2010). 48
UNDP (2010). 49
ZimVac (2009). 50
ZimVac (2009).
61
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
Free Cash PWP Cash Free Grain PWP Grain
Nu
mb
er
of
Be
ne
fici
arie
s
2004
2005
2006
2007
2008
Source: Wallace-Karenga (2009).
82. In urban areas, more than 70 percent of the employment is of an informal
nature, mostly self-employment. The majority of the informal jobs are unskilled, compared
to professional or skilled positions in the formal sector. Some of the most common informal
activities in urban areas are petty trading, retailing, artisans, and cross-border trading. Less
than 20 percent of employment in 2007 consisted of permanent paid jobs (figure 26).
Unemployment in its strict definition according to ZIMSTAT (―population aged 15 years and
above, who during the seven day reference period did not work and had no job or business to
go back to, but who were available for work‖) was relatively low in Zimbabwe from 2001 to
2007, at around 4 percent, nearly half that registered in 1993—though in urban areas it was
as high as 11 percent in 2007.51
However, unemployment rates are likely to have increased as
a consequence of the crisis. While recent official data are not available, it has been estimated
that around 300,000 youngsters (who accounted for 60 percent of the unemployed in 2004)
join the labor market every year.
83. The Basic Education Assistance Module (BEAM) is the main social protection
program aimed at retaining orphans and vulnerable children in school. Implemented
since 2001, this program provides school and examination fees assistance to orphans and
vulnerable children (OVCs) in 61 districts in order to ensure that vulnerable children do not
drop out of school. Its development objective is to prevent irreversible welfare losses among
poor households, which would otherwise resort to extreme coping mechanisms like
withdrawing children from school in response to increasing poverty. OVCs constitute around
25 percent of school enrollment. Assistance is restricted to support of school fees and levies
through block grants to schools, rather than cash transfers to individuals. BEAM provides for
community participation in the selection of beneficiaries: in theory, a Community Selection
Committee (CSC), consisting of three members of the school development committee (one of
whom is the school head), and at least six elected community representatives, is responsible
51
ICES 2001–07.
62
for the selection of children eligible for BEAM at each school.52
The program is administered
by the Department of Social Services in the Ministry of Labor and Social Services, in
collaboration with the Ministry of Education, Sports, Arts and Culture.
Figure 26: Employment Categories, 2007–08
Paid employee-permanent
19.4% Paid employee–non permanent
7.5%
Employer0.2%
Own account worker (farmer)
36.4%
Own account worker(other)
7.6%
Unpaid family worker28.9%
Source: World Bank staff calculations based on ICES 2007–08.
84. The program became almost irrelevant during the hyperinflation years, but has
recently regained coverage and funding from government and development partners. BEAM started in 2001 with near 600,000 6–18 year-old beneficiaries in primary and
secondary schools. By 2005, the program had a budget of around US$35 million, and was
assisting 970,000 pupils, representing 27 percent of enrollment (figure 27). In that year,
BEAM accounted for 24.5 percent of all beneficiaries targeted by government social
assistance programs (only behind the Drought Relief and Public Works program), and for
46.2 percent of the total resources allocated to these interventions. In subsequent years, the
coverage and the amount of resources allocated to the program diminished substantially
because of fiscal challenges. During the hyperinflation years, the program ceased because the
money channeled to schools was rendered useless even before it reached them. BEAM was
revitalized in 2009 by a new funding partnership between the government, UNICEF, and
other development partner to help support primary (560,000 students) and secondary
(243,000 students) education. Coverage will still fall short of identified needs, since the
Ministry of Labor and Social Services estimates that 990,000 OVCs require assistance to
cover school fees. Late disbursements of funds and severe operational challenges (such as
human resources in executing agencies) are also affecting the predictability continuation,
efficiency, and efficacy of the program. The inconsistency of the support provided has
apparently resulted in some former BEAM recipients withdrawing from school because
benefits have been discontinued. Moreover, in some periods, support has also been restricted
to one child per family regardless of poverty and vulnerability levels.
52
MLSS (2010).
63
Figure 27: BEAM Beneficiaries in Primary School, 2001–10
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,000
2001 2002 2003 2004 2005 2006 2007 2009 2010*
Be
ne
fici
arie
s
Source: World Bank (2006); MLSS (2010).
85. The targeting of the BEAM program needs to be improved, and its impact on
school enrollment properly evaluated. At the beginning of the BEAM cycle, which is
normally around September or October each year, projections of the number of beneficiaries
are calculated using outdated population, school enrollment, and poverty data.53 Depending
on the availability of resources, allocations are made to provinces and beneficiaries that are
selected on the basis of perceived need and vulnerability. Once beneficiaries are determined,
allocations for students are transferred directly into school accounts at the beginning of term.
Although no impact evaluation of BEAM exists, some early studies have looked into the
targeting mechanism of the program. BEAM apparently reports low errors of inclusion, with
only 5 percent of non-poor households benefiting from the program. While there is no
evidence of the magnitude of errors of exclusion, NGOs report that children with disabilities
frequently fail to receive BEAM benefits. Finally it is said that BEAM has helped maintain
the parity in school attendance, since orphans have only slightly lower primary enrollment
rates than non-orphans.
86. Aside from BEAM, Zimbabwe has no other large-scale social protection system;
other interventions are scattered, and have limited funding and coverage. Other than
BEAM, the government spends around US$6 million—one third of the social assistance
budget—on a myriad of programs with limited population coverage (table 16). Some of these
programs have a long history and large population coverage in the past: back in 2005,
drought relief programs reached 2.9 million beneficiaries; support for family in distress, and
care for the elderly reached 40,000 each; and maintenance of disabled reached 20,000
households.54
Today, the high administrative costs, combined with the low scale of the
interventions, would make them fail any cost-benefit analysis. Moreover, most of these
53
Ministry of Public Service, Labor, and Social Welfare (2006). 54
World Bank (2006).
64
programs overlap in terms of beneficiaries groups, and hence there is a high pay-off for
consolidating some of these interventions in fewer well-targeted and well-funded programs.
The country lacks a comprehensive framework that guides social protection interventions and
population priorities and actions.
87. Contributory social security schemes, such as pensions and medical insurance,
have collapsed as a result of the hyperinflation, and social assistance to the elderly is
almost nonexistent. Employment-based social protection mechanisms, such as private and
public pension and medical aid schemes, have been weakened by the effects of hyperinflation
as well few employment opportunities in the formal sector of the economy. Savings in these
schemes were almost wiped out during those years since they were denominated in the local
currency. The pension scheme covers all formal workers between ages 16 and 65 years. As
of May 2009 it had 1.5 million contributors.55
Both the employer and the employee
contribute with a 4 percent each of the actual salary, which is paid directly to the National
Social Security Administrators. As in many other countries, domestic employees and those in
the informal sector are not covered. The elderly poor do not warrant much attention in
Zimbabwe, even before the economic crisis. This results partly from the traditional belief that
the ―elderly will be looked after by their own family,‖ and that they should have made
arrangements for medical aid cover during their working life. But the situation has
substantially changed since the economic crisis, increasing their vulnerability and that of the
children they care for. For instance, in 2005, near 40,000 poor elderly were recipient of social
pensions, compared with 3,000 today.56
The proportion of households receiving contributory
pensions and life insurance benefits declined from 3.5 percent in 2001 to 1.8 percent in
2007–08.57
Aside from the poor attention they receive in public hospitals and clinics and the
demand for user fees for many services, the elderly must pay high medical aid premiums,
which remain beyond the reach of many elderly people. The country does not have
geriatricians or geriatric nurses, and public hospitals and other voluntary old peoples’ homes
have no capacity to support long-term residential care for the majority of the elderly. The
prospect of a secure old age for the majority of people remains bleak.
Table 16: Government-Funded Social Protection Interventions, 2010
Program Description Target
coverage
(2010)
Funding
(2010)
Cost per
beneficiar
y (2010)
Education sector Basic
Education
Assistance
Module
(BEAM)
Targets 618-year- old OVCs who
have never been to school, or have
dropped out of school, or are likely
to drop due to lack of funds.
243,000 OVCs
(gov);
560,000 OVCs
(donors)
US$15
million
(gov);
US$20
million
(donors)
US$62
(gov);
US$36
(donors)
55
Gandure (2009). 56
Gandure (2009). 57
ICES 2001; ICES 2007–08.
65
Health sector Assisted
Medical
Treatment
Orders
(AMTOs)
Provides fee waivers and vouchers
to indigent persons to facilitate
access to intermediate and tertiary
health services, such as a
provincial or national hospital or
other specialist facilities.
24,000 US$0.7
million
US$29
Food and nutrition sector Public Works
Program -
Drought Relief
Support
Transfers incomes to the poorest
and vulnerable households for a
limited period through temporary
employment in labor-intensive
public works activities in rural
areas.
N/A $1.1
million
N/A
Livelihoods sector Children in
especially
difficult
circumstances
Distributes cash to orphans,
physically and mentally
handicapped, homeless and
delinquent children in formal or
informal institutions.
N/A US$1
million
N/A
Support to
families in
distress
Provides maintenance allowances
and payment of transport to the
elderly, persons with disabilities,
the chronically ill, and dependants
of indigent persons.
4,140 HHs US$1
million
US$242
Maintenance
of disabled
persons
Provides assistive devices, like
wheel chairs, crutches and
artificial limbs, to persons with
disabilities.
2,000 HHs US$0.8
million
US$400
Care for the
elderly
Is a means-tested scheme targeting
the elderly poor with non-
contributory social assistance.
3,070 HHs US$0.7
million
US$228
Heroes
Dependants
Fund
Transfers allowances covering
surviving spouses and minor
children of war heroes, as well as
medical and miscellaneous
assistance.
N/A US$0.7
million
N/A
Source: Gandure (2009); MLSS.
88. In the absence of government assistance, a high proportion of Zimbabweans
migrated abroad as a coping strategy, leaving behind households that rely on their
remittances to cover living expenses. Migration can be considered as an individual or
household strategy to prevent or mitigate against shocks. Linked to this are remittances from
the emigrant to household members that remain behind. Large numbers of Zimbabweans
have migrated both internally and externally since the onset of the political and economic
crisis. Estimates of Zimbabweans in the Diaspora vary greatly, ranging from 2 million to 4
million out of a total population of 12.5 million. South Africa has the largest population of
Zimbabweans abroad, slightly over 1 million as of the end of 2007. The United Kingdom has
the second biggest population of Zimbabweans, with an estimated 200,000 to 500,000,
followed by Botswana, which is estimated to have between 100,000 to 300,000. Other
66
popular destinations include the United States, Canada, Australia, and New Zealand.
Emigration survey data show that over 80 percent of people migrating to South Africa and
the United Kingdom are between 21 to 40 years of age and have at least secondary education.
The proportion of households receiving cash remittances from distant family members was
27 percent of households in 2007, up from 20 percent in 2001.58
In provinces like Bulawayo,
Masvingo, Mashonaland East, and Matabeleland North, this share is as high as 40 percent,
while in Harare, it is only 9 percent (figure 28).
Figure 28: Percentage of Households Receiving Cash Remittances by Province, 2007–08
0
5
10
15
20
25
30
35
40
45
50
Mas
ving
o
Mas
hona
land
Eas
t
Mat
abel
elan
d N
orth
Bula
way
o
Mas
hona
land
Wes
t
Mat
abel
elan
d So
uth
Man
ical
and
Mas
hona
land
Ce
ntra
l
Mid
land
s
Har
are
Zim
babw
e
% o
f HH
s
Source: World Bank staff calculations based on ICES 2007–08.
89. Donors are filling the gap in other social protection areas, for instance by
financing cash/inputs transfers for those living in rural areas. BEAM and feeding
programs (food handouts and school feeding programs) mostly handled by the UNICEF,
DfID, USAID, and the World Food Program (which in 2005–06 had 4.1 million
beneficiaries) are the main donor-funded safety nets. Donor and NGO interventions usually
targets households headed by children, the chronically ill, the elderly, and disabled as priority
groups. One of the major program that is a model for donor coordination is the multi-donor
National Plan of Action for OVCs coordinated by UNICEF, to increase OVCs’ access to
basic services in education, health, food, water and sanitation, health care, and treatment of
HIV and AIDS. This program started in 2005 with a budget of U$86 million for a five-year
period, and aims to cover 400,000 OVCs. But in other areas, such as delivery of food aid
humanitarian assistance, donors and NGO assistance are highly uncoordinated. Smallholder
farmers are continuously supported during the agricultural season with fertilizers and other
inputs by government and donors.
58
ICES 2001; ICES 2007–08.
67
VI. Policy Recommendations
General Recommendations
90. Subject to efficient utilization of increased level of funding to the social sectors,
there would be scope to allocate more resources to social sectors in the medium-term.
Despite the well-know fiscal challenges, there is room to reallocate resources to key priority
social sectors. This is essential to allow a steady recovery of coverage and quality of service
delivery. Zimbabwe is currently falling too far from its past and regional trends in social
sector spending and performance. Indicatively, allocation to social sectors could go up to
18.5 percent of GDP in the medium-term. Table 17 proposes an indicative breakup of such
an allocation across the three sectors.
Table 17: Suggested Short-Term Budget Allocations for Social Sectors, 2012 and 2013
(millions of US$)
Area 2010 2011 2012 2013
Basic Education 292.2 469.0 564.1 620.6
Higher Education 116.0 157.0 165.9 182.5
Health 157.1 257.0 365.0 401.5
Social Protection 52.1 80.0 132.7 146.0
Total 617.4 963.0 1,227.8 1,350.6
% of Budget ** 35.3 35.0 40.6 40.6
% of GDP*** 11.6 16.0 18.5 18.5
** Assuming a growth in the budget envelope of 10% in 2012 and 2013.*** Assuming a real GDP growth and inflation of 5% each in 2012 and 2013.
* Includes Ministry of Labor and Social Services; Ministry of Women's Affairs, Gender and Community
Development; and Ministry of Youth, Indigenization and Empowerment.
91. It would also be essential to develop medium-term strategies to recover service
delivery in all social sectors. The Government of Zimbabwe is still, for most part, operating
in an emergency environment. But with macroeconomic and fiscal stability consolidation, it
is important to put in place a coherent set of policies and investments to ensure that the
Zimbabwean population, in particular the poor, can benefit from social service delivery.
There is need to establish a short- and medium-term strategy to recover social service
delivery. This should include better prioritization across goals and objectives. Due to the
prevailing circumstances, any prioritization is bound to be short-term and ad hoc, but
eventually it is desirable to have a long-term strategic plan to guide the budgeting process.
Prioritization is just part of the equation; several procurement, management, and
implementation challenges are emerging given the lack of expertise in the government after
years of skill flight. It is critical to ensure that whatever resources are dedicated to social
services are effectively and efficiently deployed.
92. Social sector goals need to be better translated in budgetary allocations. In the
absence of a medium-term plan, the budget has not been guided by a set of stated priorities.
Ideally, when planning and implementation capacity has improved, a results-based
framework with specific goals, milestones, and outcome indicators should orient budget
formulation. The government has started to do that with the formulation of the 2011 Budget,
68
although effective implementation is probably too ambitious in the short term. Better
reporting and control of what is being accomplished with budget resources is also needed.
And it is also critical to train staff in line ministries and the Ministry of Finance in modern
budgeting techniques and financial management.
93. Social sector line ministries and the Ministry of Finance need to have a more say
in managing human resources in the sectors. Employment costs are consuming most of the
resources allocated to the social sectors. While in areas like human resources for health,
constraints are enormous, in education there is room for rationalization (in particular in
secondary education) and an opportunity to introduce alternative payment schemes. Though
challenging and debatable even in member-countries of the Organization for Economic
Cooperation and Development (OECD), the government could consider piloting
performance-based payment schemes in sectors such as health, to test the viability over the
medium term to retain high-qualified staff in the public sector. Aside from extra
compensation, other examples of effective incentives to retain essential personnel in the
disadvantaged areas include career rotation requirements, business process reengineering,
and contracting out or privatizing services (box 2).
Box 2: Examples of Effective Incentives and Mechanisms to Attract and Retain
Personnel in Disadvantaged Areas
Devices for attracting and retaining personnel in disadvantaged areas can be grouped into
four broad categories.
Extra compensation: While this is often the first option considered, it has at least three
major drawbacks: limited effectiveness, high cost, and associated morale problems. Efforts to
attract expatriates back to developing countries with financial bonuses have generally proven
disappointing. This pattern is likely to apply to within-country efforts to attract staff to
undesirable locations. The evidence suggests that costs for an effective remuneration-based
strategy for attracting such skills to remote locations would almost certainly be prohibitive.
In addition, once one cadre of public service employees (such as those working in remote
locations) receives extra compensation, it is typical for pressures to mount to improve
compensation for other staff. If central authorities successfully rebuff those pressures, they
may find that morale among staff not receiving the extra remuneration drops. In short, the
extra compensation approach appears to be quite problematic.
Career geographic rotation requirements: If there is an attractive career cadre (such as
medical service) then service in a remote area (or a tough urban environment) may be
counted as a natural step in a well-ordered path, leading to (for the few) very attractive career
growth (such as eventually becoming director of medical services or head of a large,
prestigious hospital). But this is possible only if personnel management practices are subject
to effective discipline: service in remote areas is recognized, the cadre pyramid is well
structured, staff are rotated and promoted, regional staff go on tours of inspection, reports
from the field are taken seriously, remote stations are supplied with the supplies and
equipment they need, career advancement is based on merit, not patronage (which draws
staff to the center, patronage connections cannot be exploited from the periphery), pay is
competitive and prompt, and allowances fairly reflect hardship. If these personnel
69
management practices that make career advancement credible do not exist, or are weak, it is
likely to prove difficult to enforce such rotation requirements.
Business process reengineering: Resorting to itinerant service providers for services
requiring scarce skills under conditions of geographically dispersed demand is a strategy with
a lengthy and largely encouraging history, particularly in environments in which travel is
difficult and either cheap, arduous, and slow (such as walking on dirt roads) or costly, not so
arduous, and relatively quick (such as airplane travel). The service provider can take the
quick/convenient/expensive travel option, and thereby serve a large geographic area, thus
saving beneficiaries (who would mostly have to resort to the cheap, arduous, slow travel
option) much time and travail. Moreover, the service provider is afforded the opportunity to
both travel and more fully utilize his/her skills than would be feasible from a fixed location.
This strategy can yield a win-win situation when it is complemented with a strategy of
providing locally staffed paraprofessionals (modestly upgrading the skills of local low-skilled
staff to provide many of the services demanding low skills that might have been traditionally
provided by the high-skill service provider) to complement the work of the highly skilled
experts (doctors, lawyers, judges, master teachers, and others). An important difficulty that
often confronts such a strategy is resistance on the part of the high-skilled professionals, who
face a potential reduction in their ―market share.‖
Contracting out or privatization: Contracting out or privatizing the provision of particular
services (for example, through the provision of vouchers to beneficiaries, or through other
public financing mechanisms that link payments to service providers to use of their services
by targeted beneficiaries) shifts the challenge of attracting competent staff to private sector
firms. The challenge for the public sector then becomes ensuring financing is sufficient to
attract private providers; ensuring consistent and adequate beneficiary access to those
services; and ensuring that any needed minimum service or product quality standards are
respected.
Source: Reid (2010).
94. Targeting of social sector interventions should be strengthened through
transparent mechanisms that promote greater accountability. Current targeting of social
sector interventions is based on outdated pre-crisis data. It is critical to collect updated
information on poverty and vulnerability indicators to help policy makers in Zimbabwe
identify priority geographic and demographic areas of interventions, and create a unified
targeting mechanism. Within communities, either self-selection (for public works programs)
or community-level targeting (for BEAM, health assistance, or conditional cash transfers)
could be a better way to create social cohesion and transparency in the selection of
beneficiaries. Stricter adherence to guidelines and verification of selected candidates are
critical to achieve intended results. Furthermore, a centralized beneficiary database is
recommended to track targeted groups effectively and avoid program overlaps and
inefficiencies.
95. While difficult in the short-term, or even in the medium-term, Zimbabwe should
progressively embark on a path toward abolishing user fees for basic public services in
health and education, and finance them through general taxation. User fees are an
70
inefficient, regressive, and unfair way to cover funding gaps in basic social sectors, since the
most needed segments of the population get excluded from access to these services. With
economic and fiscal recovery, the government could take a stand and reduce fee for services,
either across the board or through subsidies to targeted segments of the population. User fees
could be phased out in steps, first focused on abolishing the fees for the highest priority
interventions (such as primary education, or core maternal and child health services).
96. The private sector and local communities also have potential to contribute
meaningfully to the process of achieving social sector objectives. This potential needs to
be tapped and coordinated. Though cooperation between the private and public sectors has
existed for a long time, this has been ad hoc and informal. Opportunities could be explored to
increase the capacity of local manufacturers to produce essential supplies for the education
and health sector (such as textbooks, drugs, equipment), a challenge in the case of health,
given that no drug manufacturer is prequalified by the World Health Organization.
Introduction of a comprehensive private-public partnerships (PPPs) scheme in the health and
education sectors could also lead to improved working conditions and thus attract skilled
personnel back to the sectors. Communities could also play a greater role in the management
of facilities and services, and in rebuilding infrastructure. Community infrastructure
initiatives could help better identify local priorities and create employment opportunities in
the area.
97. The government also needs to increase its role in guiding and coordinating
donor interventions. Donors have played a major role in financing social expenditures even
prior to the economic crisis, and increasingly after that. Improved government-donor
coordination is essential to ensure support to critical social service delivery while preventing
unnecessary duplication of efforts. The government should also continue to mobilize NGOs
and agencies to take up its role in service provision until it is capable of resuming these tasks
with own resources.
Education
98. Additional public resources to basic education may need to be considered over
the medium term. The share of primary and secondary education in the budget, at 17.1
percent, has fallen below historical rates of 25 percent in 2000–05 and below what is required
for efficient delivery of educational services and achieving desired outcomes. On a per capita
basis, it would be advisable to raise public financing of the sector from the current amount of
US$115 and US$200 per student in primary and secondary education respectively to at least
US$140 and US$255 respectively. Over the medium term, public funding for basic education
should be raised progressively to account at least 8.5 percent of GDP (as back in 2005), up
from the current 7.8 percent. These additional resources should prioritize nonwage recurrent
expenditures (such as teaching materials, school grants, supervision, and information
systems) and some capital expenditures (mostly on water and sanitation in schools), and
avoid further increases in payroll costs.
99. A further increase in the basic education budget could be achieved by
reallocation from higher education. Public funding of tertiary education is usually
71
inequitable since most of the benefits of higher education are captured by a small segment of
student population. The government spends $1,800 per year per student on higher education,
more than ten times what it spends on primary or secondary education. In some national
universities, government subsidies even surpass fees collected from students. More than 70
percent of the government budget in higher education goes to transfers and capital
expenditures for nine public universities, in sharp contrast with virtually nonexistent
infrastructure projects in primary and secondary schools.
100. MOESAC needs to have a stronger role in teachers’ management, the largest
component on the basic education budget. While overall salary increases to teachers will
be severely constrained over the medium term until the government recovers its capacity to
collect additional revenues and create fiscal space for other critical expenses, it may be worth
a consideration providing certain limited benefits and allowances to motivate teachers to
deliver quality education and retain workers in rural areas. But this should be complemented
with tighter staffing rules. Given that teacher absenteeism seems to be a major problem, steps
to both reliably monitor it and penalize absentee teachers (for example, through payment
freezes, or reduced chances for promotions) should be explored, while at the same time
resources for supervision should be increased. Within basic education, there is more room for
rationalization in secondary education than in primary education, which already has a very
high pupil-to-teacher ratio. During the formulation of the 2010 Budget fiscal year, MOESAC
did not know the actual wage bill for teachers even at the time of the budget preparation
budget.
101. There is a need for better coordination among ministries with competence over
the basic education sector. MOESAC is not the only ministry with competence over basic
education. For example, teacher service conditions are determined by the Public Service
Commission, pre-service training is the responsibility of the MHTE, and the BEAM that
covers school fees for vulnerable children falls under the jurisdiction of the Ministry of Labor
and Social Services. Better coordination and shared understanding of objectives and priories
are critical in implementing sound education and training policies successfully.
102. Aside from supply side interventions, cost reduction policies are needed to
increase demand for education and keep children in school. BEAM is a good example of
demand-side interventions that succeed in increasing primary school enrollment. However, it
only targets OVCs, and many families cannot afford the cost that school attendance entails in
terms of user fees, textbook, transport and uniforms. Efficiency gains should be pursued to
reduce costs and consequently user fees, with the ultimate goal of eliminating fees over the
medium to longer term, and possible leaving discretionary voluntary fundraising power to
schools. For instance, some schools are awarded grants to purchase learning materials in
classrooms, but these are often insufficient. Either these grants should be augmented, or those
funds should cease to be earmarked and channeled to cover overall school expenses that
allow institutions to lower school fees. Financial recordkeeping in schools should be
improved and the staff in charge properly trained, to ensure proper allocation and utilization
of funds provided by the government and communities: such information is essential to avoid
waste of scarce resources and ensure optimal and cost-effective resource allocation. Finally,
in the case of school uniforms, cited as one of the reasons for taking children out of school, it
72
is recommended that MOESAC relax the uniform code, at least until some of these funding
challenges are resolved.
Health
103. Public health expenditures would need to be scaled up to restore essential service
delivery. It is important for the Government of Zimbabwe to consider higher per capita
allocations to the health sector to achieve the short-term goal of revitalizing basic health
services, especially at primary levels. Without such investments, the recovery of the health
sector will likely take longer to achieve, thereby delaying the population’s ability to access
improved health services. The government is currently spending just US$20 per capita in the
health sector, or 4.3 percent of GDP, which is insufficient to cover even the most basic
services. The recent strategy put together by MOHCW requires about US$30 per capita, or 6
percent of GDP, on public expenditures. An increase in sector budget for 2012 should
however be contingent upon efficient utilization of the existing level of resources and re-
prioritization within the sector. Progressively, the sector should increase its share of the
budget from the current 9.3 percent to 15 percent over the medium term, as indicated by the
MOHCW National Health Strategy, in line with the 2001 Abuja Declaration on financing
communicable diseases.
104. Within the health sector, budget allocations need to be rebalanced, assigning
more priority to restoring basic health services in rural areas over capital expenditures
in central hospitals in urban areas. A more balanced budget directed toward preventive
health care services and support structures rather than curative care is needed. Currently,
insufficient budget goes to expenditure categories that are likely to have the biggest impact
on public health and development , such as mother and child health, and HIV/AIDS, malaria,
and TB control, as defined in the MOHCW National Health Strategy. Therefore, it is critical
to resume the provision of basic packages of preventive health care. Health infrastructure and
human resources also need additional budget support to restore service delivery and
guarantee uninterrupted supply of core essential pharmaceuticals and other medical supplies.
Currently, infrastructure, equipment, and treatment in urban central hospitals greatly outstrip
allocations in poor rural areas.
105. Chronic malnutrition needs to be raised as a policy priority in Zimbabwe. No
intervention is currently in place to address micronutrient deficiencies in infants and young
children, along with promoting appropriate complementary feeding practices. Current
nutrition interventions are short-term and poorly coordinated, have low coverage rates, and
are largely centered on screening and treating severely acutely malnourished children in
health clinics. Chronic malnutrition should be considered a development priority and a long-
term plan to address the problem of stunting in young children needs to be put in place.
106. In terms of other priority areas to focus health interventions, the following are
high pay-off recommendations:
o Increase skilled delivery and improve the quality of care provided at antenatal
visits, delivering packages of high impact interventions (such as blood
pressure machines, weigh scales, and hemoglobin meters).
73
o Maintain essential drugs and medical supplies, and initiate a pharmaceutical
sector reform (including responsibilities of NatPharm).
o Resume the provision of safe water and sanitation to contribute to the
reduction of morbidity and mortality from diarrheal diseases.
o Revitalize training of health workers, including in-service, on-the-job training
(such as obstetric skills of primary care nurses) and support by senior medical
consultants, especially for district hospital levels.
o Retool, and redeploy these workers at primary care level across the country,
since they yield greater returns for the entire health system
o Rebuild transport and telecommunications for referral and supervisions, and
ensure electricity supply for hospitals and clinics.
o Resume infrastructure works in ongoing health center projects, which should
receive priority in the order of interventions.
o Undertake a health facility assessment to properly determine the current state
of medical equipment and health infrastructure, and help prioritize capital
expenditures.
107. In human resource management, the current donor-funded salary supplements
scheme is unsustainable in the long run and the government should prepare for its
ultimate phase-out, possible replacing it with a results-based financing framework to
retain workers, mainly in rural areas. Donors are contributing to retain health workers by
providing salary supplements. While these schemes have been successful in stopping brain
drain out of certain specializations and less attractive locations, they are unsustainable over
the medium term since they depend on donors’ willingness to continue providing resources.
Moreover, they create tension and fail to fill expectations among those not participating in
the scheme. The government should come up with an exit strategy by assuming these higher
employment costs in the future. That could also provide an opportunity to start rewarding
performance in service delivery through a results-based financing framework. Also, the role
and quality of village health workers needs to be revamped, including retraining (for
example, of primary care nurses)..
108. Demand-side interventions could help improve targeting of health services.
Demand-side stimulus to use health services is nonexistent in Zimbabwe. While supply side
efforts are commendable, it is also necessary to ensure that mothers fully understand the
importance of vaccinations to guarantee the child’s good health. Cash transfers and fee
waivers for mothers could be conditional on children completing a full set of vaccinations (as
in many CCTs interventions around the world), providing that monitoring and good record-
keeping mechanisms are in place to prevent cheating, and linking of such information across
health care providers is effective (since mothers may visit multiple clinics). These transfers
could be complemented by well-designed health education and promotion interventions at
rural and peri-urban community levels, where most mothers reside. Similarly, vouchers for
transporting woman at risk could be considered, to incentivize deliveries at the hospital level.
Alternatively, the government should consider revitalizing the Assisted Medical Treatment
Orders (AMTOs) vouchers for indigent persons to increase access to intermediate and
tertiary health services.
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109. New avenues for private-public partnerships (PPPs) in health care should be
explored. In urban areas, opportunities for private sector participation in hospitals should be
vigorously examined and exploited. Certain priority health services could also be outsourced
to the private sector, and NGOs could be contracted to undertake specific tasks for the
government. It is also necessary to strengthen private partner networks in service delivery to
reduce duplication and increase efficiency of the system.
110. Expenditure management and budget planning should be strengthened in the
health sector. It is critical to identify priorities and funding for primary services, including
outreach services, vaccinations, maternal health, and HIV and AIDS prevention, which need
to be properly estimated based on available evidence. Budget allocations should match these
priorities. Financial resources to provinces should also become better aligned with the need
of the populations, including revising the resource allocation to lower-level institutions.
MOHCW should develop a model that can be used to justify funding levels to hospitals,
church hospitals, and local authorities using objective and needs-based criteria. To achieve
this, is important to strengthen the health information system for planning support. In the
medium term, linking allocations to specific outputs or outcomes may further sharpen this
process.
Social Protection
111. It is important to set the building blocks of a social assistance framework that
establishes a minimal livelihood floor below which citizens will not be allowed to fall.
The government needs to use this interim period of fiscal and economic consolidation to
carry out a comprehensive review of social protection framework for its people and
formulate a more integrated and inclusive social protection system. In the meantime,
nongovernment actors will continue to play a supportive role, but should follow a vision and
strategy as envisaged by the government, which should progressively assume some of these
responsibilities with time.
112. It is possible to consolidate interventions into a few integrated programs with
higher coverage and reduced administrative costs. With the exception of BEAM, social
assistance interventions financed through the budget are extremely underfunded, with a few
programs with negligible coverage consuming up to one third of the social assistance budget
merely on administrative costs. This is both a consequence of lack of funding and lack of a
consolidation strategy based on priority groups of intervention. The Ministry of Labor and
Social Services should continue with only a few of these interventions with meaningful
funding and eliminate the rest or leave them for donor humanitarian assistance.
113. Conditional cash transfer (CCTs) interventions have proven to be very effective
in increasing demand for basic social services, particularly in health and education.
International practices suggest that to maximize the impact of cash or in-kind social
assistance, beneficiaries should be asked to fulfill certain corresponsibilities. These are called
―conditional cash transfer‖ (CCT) interventions. These CCT experiences are already in place
in neighboring countries such as Malawi, Mozambique, and Zambia, and in many other parts
of the world. In the Zimbabwe context, the BEAM program could reduce leakages and have
75
greater impact on school enrollment by transferring resources to users under the condition of
strict education attendance levels (if monitoring and enforcement mechanisms can allow it),
instead of channeling funds to the institutions. Similarly, the health sector could explore
channeling transfers to households in extreme poor areas conditional on their children being
fully vaccinated and regularly visiting health centers. Subsidies delivered through food
packages and agricultural inputs could also be progressively transformed into cash assistance
tied to human capital behavior, to allow for a more transparent and efficient use of funds.
Delivery of cash transfers has several advantages over delivery of physical commodities: i) it
is usually less expensive to transfer since program designers can take advantage of electronic
transactions; ii) it reduces costs and opportunities for corruption; iii) it allows a greater
degree of flexibility, enabling recipient households to allocate the resources to the most
critical needs; and iv) it stimulates local economies and provides a multiplier impact with
broader benefits. The provision of food, by contrast, for example, can compete with local
producers and destabilize local markets. Of course, transfer schemes pose important
challenges in terms of delivery, monitoring, and keeping transparent registries of
beneficiaries. A basic requirement, for instance, is the availability of a wide system of rural
banking networks to make the cash grants system work. For cases where demand-side
constraints are less of an issue, or poor enforcement mechanisms exist, unconditional
transfers would be more appropriate given the lower administrative costs and similar impact
they may achieve.
114. Public works programs should be resumed; they are an excellent way to transfer
resources to local areas with interventions that support rehabilitation of community
infrastructure. Given recurrent natural and economic crises that leave a substantial portion
of the population without access to income or food, and the fact that the country’s physical
and economic infrastructure is in a state of disrepair, it would be wise to set up a scheme that
provides cash (recommended), food, or agricultural inputs in exchange for some level of
work requirements and the rehabilitation of physical infrastructure in periods of crisis.
Zimbabwe has experiences along these lines, like the Drought Relief and Public Works
Program, which is currently underfunded. However, the success of these labor-based relief
programs in post crisis contexts like the one that Zimbabwe faces rely on solid technical
planning, monitoring, and supervision of projects identified by local authorities and
communities. Such projects could be in the construction and maintenance of local clinics,
schools, sewage works, water systems and roads, but in general should be as labor-intensive
as possible to maximize their local employment impact. Self-selection (willingness to work
at the offered wage level) is the most appropriate targeting mechanism within communities
for these types of programs. Due to their nature, execution of public works programs require
actions that are multisectoral, going beyond the Ministry of Labor and Social Services alone
to include other ministries such as Agriculture, Public Works, Housing, Education, Health,
Finance, and Planning.
115. Overall, additional resources will be needed for social assistance interventions to
make an impact on intended beneficiaries. With help from development partners, the
recommendation is to continue and strengthen BEAM, and start piloting conditional cash
transfer schemes and public works interventions to rebuild community infrastructure.
Covering all OVCs in primary education in 2012 would require at least an additional US$20
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million from government sources. A pilotconditional cash transfer tied to health and
schooling requirements to be initiated with 40,000 extremely poor families in 2012 with
support of US$20 a month would require around US$10 million (including administrative
costs). And a pilot six-month public works program for labor-intensive community projects
that target 50,000 participants in rural areas in exchange for US$50 a month would require
around US$20 million (including administrative and material costs). In the medium term,
resources for social protection should aim to reach at least 2 percent of GDP.
116. In parallel, the government should play a major role in supporting integration
and complementarities of its initiatives and those provided by NGOs, the UN agencies,
and other stakeholders. For a long time, social protection activities have been implemented
mainly through NGOs using donor funds. The gradual integration of donor/NGOs
interventions and sharing of lessons learned with government strategies will be particularly
important to facilitate a gradual transfer of responsibilities to the public administration to
ensure sustainability of interventions.
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