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

auxoliar.doc#_Hlk284240400


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


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


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


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).


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



Services

Transfers and

Programmes

Fixed capital

assets

Capital

Transfers

Sou


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


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


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



Services

Transfers and

Programmes

Fixed capital

assets

Capital

Transfers

Areas


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)


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



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



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


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

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Ta

nza

nia

Ma

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uru

nd

iM

ad

ag

asc

ar

Ug

an

da

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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

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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


Figure 19: Diarrhea Prevalence for Children under Five


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


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

%


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


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

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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


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

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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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Gandure, S. 2009. ―Baseline Study of Social Protection in Zimbabwe.‖ Multi-Donor Trust

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UNICEF (United Nations’ Children Fund). 2010. ―Situation Analysis on the Status of

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