Human Rights Bulletin Number 41 February 2009

The right to health in

What the right to health entails The right to health is the right to the enjoyment of a Under the general obligations clause of Article 2 (1) of variety of facilities, goods, services and conditions the International Covenant on Economic, Social and necessary for the realization of the highest attainable Cultural Rights, a State Party is required to take standard of health. This right is guaranteed not only by legislative and other steps to the 'maximum of its available timely and appropriate but also by resources', with a view to achieving 'progressively' the full determinants such as access to safe and potable water, realization of the rights recognized in the Covenant, adequate sanitation, an adequate supply of safe food, including the right to health. This means that the nutrition, housing and access to health - related Government of Zimbabwe has a legal obligation to all its education and information. citizens to be concerned about their health needs. This Human Rights Bulletin has been prepared against a background of the collapse of basic service delivery such Furthermore, the 1998 Maastricht Guidelines on as health, education and food in Zimbabwe. The aim of Violations of Economic, Social and Cultural Rights this particular Bulletin is to examine the collapse of the notes in Guideline No. 10 that “resource scarcity does not health system in Zimbabwe and to consider the relieve States of certain minimum obligations in respect of Government of Zimbabwe's (GoZ) international their implementation of economic, social and cultural rights”. obligations in terms of guaranteeing the right to health Thus if the Zimbabwe government should argue that it for its citizens, and the internationally accepted is unable to meet its minimum obligations to the right to benchmarks that the Inclusive Government must aim to health for its citizens because of a lack of resources, it achieve to ensure the attainment of 'the highest standards must at least be able to demonstrate that every effort has of living' for all Zimbabweans. been made to use all resources that are at its disposal in an effort to satisfy those obligations.

Apart from these obligations, international law creates a The Right to Health and number of legal obligations on every state to respect, Zimbabwe's International protect, promote and fulfill the enjoyment of human rights by all those under its jurisdiction. The obligation Obligations to respect health rights requires the Government of Zimbabwe is party to legally binding treaties such as the Zimbabwe, and thereby all of its organs and agents, to International Covenant on Economic Social and desist from carrying out any discriminatory and Cultural Rights (ICESCR) and the African Charter on retrogressive practices or sponsoring or tolerating any Human and Peoples Rights among other treaties that practice, policy or legal measure violating the rights of observe the right to health. Article 12 of the International the individual to health. In Zimbabwe's case the Covenant on Economic Cultural and Social Rights states that: responsibility to respect health rights requires the State The States Parties to the present Covenant recognize the to refrain from such acts as sending away patients from right of everyone to the enjoyment of the highest attainable health centres because they are members of an standard of physical and mental health opposition political party. Concurrently, the obligation to protect the right to health approved and unexpired drugs, safe and potable water, and obliges the State and its agents to prevent the violation of adequate sanitation. any individual's right to health by any other individual or non-state actor. The Government of Zimbabwe, The collapse of health service therefore, has a duty to protect its people by making sure delivery in Zimbabwe that the privatization of health services does not interfere with access to such facilities by poor people, and that Since 2000, the GoZ has failed to provide an efficient and medical practitioners and other health professionals effective basic health care system. A myriad of factors meet appropriate standards of education, skill and caused by poor governance and the collapsed economy ethical codes of conduct. have manifested themselves in the flight of qualified health workers, poor remuneration, insufficient funds for the Ministry of Health and Child Welfare to run health programmes, lack of drugs in health institutions, Clarifying what governments are poor water and sanitation facilities right across the not obliged to provide country and expensive, unaffordable health care. All these problems have culminated in various crises such as The Committee on Economic Social and Cultural Rights the , the partial or complete closure of in General Comment 14 (2000) clarified that the right to central referral and district hospitals, and the general health is not to be understood as a right to be healthy. collapse in the health delivery system. The Comment notes that the aspirations to the highest attainable standard of health should be balanced between an individual's state of health and a state's available resources. Notwithstanding a state's access to The Cholera epidemic financial resources or otherwise, a state cannot provide The August 2008 cholera outbreak became the latest protection against every possible cause of human ill- blow on Zimbabwe's ailing health delivery system. The health some of which can be as a result of genetic factors epidemic caused a huge strain on the health facilities that and the adoption of risky or unhealthy lifestyles by were still functional. The World Health Organization individuals. However, the GoZ is obliged in its provision estimates that as at the end of February 2009, 3 8791 of the right to health to guarantee the availability, patients out of 83 631 cholera cases had died while the accessibility, acceptability and quality of health services. disease has now spread to rural areas where conditions These fundamentals are elaborated on below: in terms of access to health care are even worse and the death toll is likely be higher than recorded. A person a) Availability – Functioning public health and health care may get cholera by drinking water or eating food facilities, goods and services have to be available in sufficient contaminated with the cholera bacterium. In an quantities. These will include the adequate provision of safe epidemic, the source of the contamination is usually the water, hospitals, trained medical personnel receiving faeces of an infected person. The disease can spread domestically competitive salaries and essential drugs. rapidly in areas with inadequate treatment of sewage and drinking water. A large-scale outbreak of cholera b) Accessibility – All the determinants mentioned above have was inevitable in Zimbabwe following serious problems to be accessible in all dimensions, which include a guarantee to with the provision of safe water and adequate sanitation non-discrimination on any grounds be they political, or in most urban areas for several years. Suburbs in most otherwise. Moreover, health facilities, goods and services must urban areas can go for months without a drop of water be within safe physical reach for all sections of the population coming out of the taps. Others such as Mabvuku and even in rural areas. Health facilities and services must also be Tafara in have gone for years. Broken down affordable to all citizens. sewerage systems and burst sewer pipes have resulted in raw sewage flowing daily in drainage systems and in c) Acceptability – Health facilities, goods and services must the streets of densely populated residential areas. be respectful of medical ethics, culturally appropriate as well as being designed to respect confidentiality of those concerned. After a period of denial and a deliberate violation of d) Quality – Health facilities must also be scientifically and citizens' right to information, the GoZ eventually medically appropriate and of good quality. This requires, declared cholera a national emergency on 4 December among other things, skilled medical personnel, scientifically 2008, four months after the outbreak began. This resulted in increased efforts to combat the outbreak by both international and local non- governmental

1At the time of printing this report, 8 April 2009, 4 186 deaths had been recorded.

2 organizations. However, the GoZ continued to whole economy dollarized such that even health services flagrantly violate the right to health for Zimbabweans are now being charged in foreign currency. This move affected by cholera by making false pronouncements that has pushed health care beyond the reach of many were clearly intended to mislead people and the Zimbabweans who do not have access to foreign international community that the epidemic was over. On currency. Both government and private hospitals and 11 December 2008, the government declared the cholera any other health institution are now charging in foreign epidemic over. By failing to provide citizens with useful currency with charges in local currency being information about the epidemic the GoZ could be found determined on a daily basis in line with the prevailing in breach of its international obligations as it gave people exchange rate of the US dollar against the Zimbabwe false information regarding the epidemic. dollar. In addition, virtually all pharmacies are selling their drugs in foreign currency. This is a huge blow to most Zimbabweans considering that only less than 10 % of the population has direct access to foreign currency. In Closure of public medical any case, the exorbitant prices being charged by the institutions service-providers also inhibit those who might have access to the foreign currency. This situation increases The epitomy of the collapse of the health delivery system vulnerability for the sick especially those infected by was the closure of the major referral hospitals in HIV/AIDS as they need constant medical attention and Zimbabwe. First it was the closure of Parirenyatwa and medications which are now placed at restrictive costs. Harare Central Hospitals and then other major hospitals countrywide. The Medical School stationed at Parirenyatwa Hospital, the major supplier of student doctors, was equally affected as it was shut down along Brain drain of health with the teaching hospital. These two institutions are professionals major referral centres thus their closure would affect a huge number of citizens seeking medical attention. With Over the past years, Zimbabwe has been experiencing a most small clinics that operate in the rural and urban massive exodus of health professionals. Doctors, nurses areas functioning with the barest minimum of staff and and other medical professionals such as radiologists are supply of drugs, they too were as good as closed. Reasons leaving the country in search of greener pastures. These that were given for the closure of the hospitals were, medical practitioners are leaving for countries such as the among others, lack of running water, toilets United Kingdom, South Africa and . This overflowing and non-availability of essential massive exodus has resulted in most public health medicines and supplies. All these reasons point to the institutions being under-staffed with the remaining staff lack of seriousness on the part of GoZ to prioritize health failing to cope with the huge amounts of work. It is service delivery in Zimbabwe. The closure of major difficult to establish the number of health professionals public health institutions subjected patients (including who have left the country, but a previous study done in 2002 suggests that Zimbabwe was the United Kingdom's the poor who have no access to foreign currency) to 2 private medical care that was beyond the means of many fourth largest supplier of overseas nurses then . That Zimbabweans. Medical fees in private hospitals range same study quoted the Minister of Health and Child from US$200 cash for consultations to US$3000 for Welfare saying that Zimbabwe was losing an average of operations such as Cesarean section. 20% of its health care professionals every year and that 18,000 nurses had left since 1998. The rapid economic decline since this study was conducted, only suggests “Dollarization” of the economy that the number of health professionals leaving the and health care in Zimbabwe country has increased greatly.

Since the Governor of the Reserve Bank of Zimbabwe's 10 The remaining health personnel usually serve in private September 2008 introduction of payment in foreign hospitals where they are also overwhelmed with work currency for certain services, many other services which means that those patients who go to the providers have sought licences to do so. What has Government hospitals will remain exposed to transpired is that, the GoZ has proceeded to have the institutions which do not have adequate medical staff.

2See Abel Chikanda, 2005 Medical Leave: The Exodus of Health Professionals From Zimbabwe, Southern African Migration Project Series

3 HIV and AIDS The collapse of the health care delivery system has dealt a the outcome to the Committee on Economic Social and major blow to HIV and AIDS patients. Zimbabwe is one Cultural Rights. country in Sub-Saharan Africa that has a high rate of HIV prevalence. According to UNAIDS, Zimbabwe's HIV prevalence rate is 15.3% for those aged between 15 and On 30 January 2009, the Movement for Democratic 49. It is estimated that 1.3 million people are living with Change (MDC) agreed to form an inclusive government HIV in Zimbabwe and that 3 200 people die every week with Zanu PF and the other MDC formation. This was a because of AIDS. The collapse of the health care system landmark decision as it gives impetus to the coupled with the dire economic situation in Zimbabwe, implementation of the Global Political Agreement signed has caused huge suffering to HIV and AIDS patients by the political parties on 15 September 2008. There is a particularly those who were on medication. Patients who lot of work to be done by the inclusive government in are on Anti Retroviral Therapy are experiencing terms of restoring the right to health of the Zimbabwean difficulties in accessing their medication due to the non- c i t i z e n s . B e l o w a r e c o r e o b l i g a t i o n s a n d availability of subsidized drugs from the GoZ. People recommendations of which the inclusive government in living with HIV/AIDS have special nutritional Zimbabwe should take note: requirements which they cannot afford to meet in the lensure the equitable and non-discriminatory current economic climate. They can no longer afford to access to health facilities especially for have proper and sufficiently nutritious meals. This has vulnerable and marginalized groups; resulted in a higher mortality rate for people living with HIV/AIDS as the inadequate nutrition further lensure access to the minimum essential food compromises their immune systems. which is nutritionally adequate and safe;

lensure access to basic sanitation and an adequate Recommendations supply of safe and potable water; Under articles 16 and 17 of the Covenant on Economic Social and Cultural Rights, States parties are expected to lprovide essential drugs to take measures to submit periodic reports to the Committee on Economic, prevent, treat and control epidemic and endemic Social and Cultural Rights within two years of the entry diseases; into force of the Covenant for a particular State party, and thereafter once every five years. These reports are to outline the legislative, judicial, policy and other lprovide education and access to information on measures, which States would have taken to ensure the health problems affecting communities enjoyment of the rights contained in the Covenant. States including methods of preventing and parties are also requested to provide detailed data on the controlling them; degree to which the rights are implemented and areas where particular difficulties have been faced in this ladopt and implement a national public health respect. Zimbabwe last furnished this Committee with a strategy and plan of action which includes health report in 1995. There is an urgent need to take stock of the indicators and benchmarks by which progress realization of economic, social and cultural rights in can be monitored. general and the right to health in particular and report on

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