B r i t a i n Z i m b a b w e S o c i e t y
OF Report Section 2
PANEL ONE: ISSUES AND CHALLENGES –
THE ZIMBABWEAN DIASPORA AND ITS DYNAMICS
Lela Kogbara (Chair) started by saying she was sure she spoke for all present in expressing grave concern for those demonstrators assaulted and detained by police in Zimbabwe in the last week. Lela also echoed Margaret Ling’s dismay at the refusal of Raymond Majongwe’s entry visa, and suggested that the forum should give careful thought to anything that we (in this forum) may be able to do in solidarity with Raymond and his colleagues in Zimbabwe. With this context in mind, Lela expressed ever greater appreciation for the presence at the forum of the first two speakers, who had both come direct from Zimbabwe and she now invited to address the forum.
Dr Stephen Munjanja, currently a consultant obstetrician at Harare Hospital and a member of the WHO task force on Reproductive Health for Sub-Saharan Africa, gave the first presentation as follows:
The Skills Crisis in the Health Sector in Zimbabwe
The key health care challenges facing Zimbabwe relate to HIV/AIDS and TB, malaria, maternal health, and infant and child health. In recent years there has been a critical deterioration in the resources available for combating these challenges, and a serious deterioration in the broader socio-economic context that is such an important platform for good health. This means that there has also been a massive deterioration in the health of Zimbabweans as a whole. Where twenty years ago, the average life expectancy of a Zimbabwean was 65 years, it is now 28 years. This is an extraordinary drop in life expectancy and reflects the dire conditions that prevail in the broader Zimbabwean context and that impact significantly on health.
HIV/AIDS has an enormous impact on health, bringing a massively increased burden of disease to bear on both resources and people, both directly and indirectly. Its impact on people’s health is direct in that the 40% infection rate means that a significant proportion of the population are sick so they cannot work and find themselves in need of urgent medical care, or are dying. Its indirect impact occurs through the fact that it is primarily people between the ages of 15-45 who are infected. Not only are these people unable to do the work they would normally do to support their families, but they are unable to care for their children, and the burden of both work and care then falls increasingly to the elderly or to slightly older siblings. This not only makes them poorer and less able to afford medical care, but it also makes the elderly obliged to work harder than ever, making them more vulnerable to exhaustion and more likely to need care; in the meantime, young people looking after younger siblings are forced to work early, deprived of an education, and even less likely to be able to afford to support those they need to support. Furthermore, the expense of treating HIV/AIDS and all its related illnesses means that significant resources are diverted from other needs in the health service, draining its capacity on a wider scale. All of these factors mean that HIV/AIDS is responsible (both directly and indirectly) for a huge increase in the demands being made on the health system; and all this is at a time when the health system has fewer and fewer resources with which to respond to any demands.
The Zimbabwean health service has lost a large number of skilled workers in recent years, including health workers of particular importance such as Doctors, Nurses, Pharmacists, Physiotherapists, Radiographers, Laboratory Technologists, Dental Practitioners and many others. Ironically the vital skills of these workers have been lost to other countries where HIV prevalence is far lower and anti-retroviral treatment is available. This movement out of the country has also been accompanied by a vast reduction in the number of foreign medical workers that come to work in Zimbabwe, whether for a short few months or for longer, and by diminishing amounts of foreign support for our health infrastructure. Overall the loss of skills relates directly to the context of socio-economic decline, as it means the health service is unable to offer the resources that medical practitioners need to successfully challenge such a high HIV prevalence rate. As a personal illustration, I have had 3 occasions where I have been vulnerable to HIV infection after suffering a needle prick during surgery on an HIV+ patient. On these three occasions I have needed to get anti-retroviral prophylactic treatment within 12 hours to prevent HIV infection from taking place; in each case, I had to drive to Harare from Rusape at 3AM to wake up a pharmacist that I know has the medicine to sell me. I am really only able to access this treatment in this way because I am a Doctor and I know a pharmacist who can help me. If I were not a Doctor, I would not be able to access such treatment nearly so easily, so immediately, or at a price I could afford.
The extent of the skills drainage is sharply illustrated by the declining medical practitioner-population ratio:
Doctors Nurses
Zimbabwe 1: 6250 1: 1400
South Africa 1: 1300 1: 250
UK 1: 400 1: 80
(WHO 2006)
The above figures conceal further problems. Proportionally, the loss of specialist skills among nurses is even greater than is suggested by absolute numbers. Out of 425 doctor posts in the public service, only 105 are filled – that is only 25%. Even fewer (only 21%) of district medical officer posts are filled – in Manica province alone there are 4 district hospitals that have no doctors at all. Some midwifery schools are actually facing closure, and overall 50% of all health posts are presently vacant.
The figures below compare Zimbabwean, South African and British per capita expenditures on health at the international dollar rate:
1999 2003
Zimbabwe 91 47
South Africa 244 258
UK 1370 2047
(World Health Report 2006)
The fact that Zimbabwe spends so little money on health provision might be said to reflect the current state of the economy and the desperate scarcity of resources in general; but it also reflects government’s inadequate expenditure on health as a percentage of overall general expenditure. The African Union recommends 15% as an appropriate proportion of general expenditure for governments to spend on health, yet in the midst of a health crisis, Zimbabwe spends only 12%.
Government expenditure on health as % of general expenditure:
1998 2002
Zimbabwe 12.2 12.2
South Africa 11.5 10.7
Western Europe 18-20%
(World Bank 2002 and 2005)
Target for Africa 15%
Lack of expenditure on health has lead to diminishing resources for the treatment of patients but it has also lead to serious problems of inadequate remuneration for medical practitioners. This has combined to create poor working conditions and a difficult work environment with little incentive for medical practitioners to remain and growing incentives for them to emigrate to the properly resourced and better paid jobs that await them elsewhere. In many of the last few years, Junior Doctors have been on strike for up to three months.
More recently, government has made some effort to reverse this skills loss, but to little avail. The Ministry of Health created a Health Services Board to oversee issues of pay and ensure the training of different categories of health workers in adequate numbers. They have recognized the problem of remuneration and offered financial incentives for practitioners to stay, but these are eroded by galloping inflation almost as soon as they are in place; the incentives offered have not been enough to prevent practitioners from taking up better offers elsewhere. One difficulty is that in competing with the ‘pull’ to practice elsewhere, the incentives offered to medical practitioners inevitably exceed those offered to other professions (eg engineers). This is partly because the skills and experience of medical practitioners in Zimbabwe are frequently broader and more developed than in other countries where the demands placed on them are not so great. For example, nurse training in Zimbabwe places greater emphasis on more developed skills than nurses are expected to have elsewhere. Greater reliance is placed on nurses being able to carry out particularly skilled practices that they are not permitted to do elsewhere (e.g. Caesarean Section). Attempts have been made to bond health workers to working in Zimbabwe after their training programs, but these have been impractical and unsuccessful. Similarly, there were attempts to establish bilateral agreements (e.g. with South Africa), but these did not work as they have simply displaced the destination from one country (eg SA) to another (eg Namibia).
Zimbabwe can do very little that is effective in reducing the ‘pull’ factors that drain its skills, and this will continue until it can significantly reduce the ‘push factors’ that make it hard for people to stay in the country. Solutions that go some way to helping with this at a practical level include acquiring greater financial support for electronic resources and equipment, or furnishing more direct support through basic tools like books, laboratory equipment and technology. Some key strategies for this include the creation of links between professional associations (eg Zimbabwe Nurses Association and UK Nurses Association), and more effective channels for more regular communication; a reduction in unnecessary obstacles (particularly those of a bureaucratic nature) to this sort of liaison; and a regular monitoring of the impact of this. It is in this way that Zimbabweans in the Diaspora can continue to use and maintain their own skills while making a really important contribution to sustaining the skills base that remains in the country, its future development, and the broader transformation of the socio-economic context in which health issues arise. It has been a challenge to develop and implement interventions that are effective, but as long as communication between Zimbabweans at home and in the Diaspora remains active and continues to engage their skills in a sustainable manner, it may be possible. For this to happen, the involvement of the Diaspora should have specific achievable objectives, and must include constant communication with civil society and professional organizations in Zimbabwe, so that the impact of any action can be monitored properly and then future action can be developed effectively.
Thabitha Khumalo, third vice president of the Zimbabwe Congress of Trade Unions, gave the second presentation. Thabitha had prepared a formal presentation in advance, but on the day itself preferred to speak to the Forum about the arrests of her colleagues using the preceding days as a lens through which to consider the role of the Diaspora and Zimbabwe’s problems in the current context. Both presentations (spontaneous and planned) are reproduced below.
Thabitha Khumalo Spontaneous Remarks:
Earlier this week, ZCTU members and supporters held a demonstration protesting the economic mismanagement of the country and repeated incursions on civil, political and economic rights by Government. We were also demanding the right to get effective treatment for HIV/AIDS in the form of anti-retroviral medication.
Over 400 of my comrades were arrested, beaten up and jailed. They were badly beaten up, sustaining serious wounds, as a result of which my President and Vice President are unable to walk. Other Comrades also have very serious injuries including one who has a deep wound in the head and is unable to speak at all.
The labour movement has experienced great difficulties in challenging the brain drain, a situation that has not been helped by draconian legislation passed by government. For example, the Communications Bill will prevent the e-learning possibilities that the previous speaker referred to. In passing draconian legislation, Mugabe is much worse than Ian Smith was and while it is sometimes effective, people eventually find ways round it. Unjust laws have to be violated so that we can challenge them in the courts of law, and as a result of this and such things as Operation Murambatsvina, the only homes we know in Zimbabwe are jail and hospital. The law courts are not impartial but we must still try to use them in any way we can. After transformation, we will revoke unjust laws and rebuild an effective judicial system.
Zimbabweans used to have an education system that we could be proud of, and now Zimbabweans in the Diaspora are hitting the books to take improved skills back home. But the irony is that the Colonizer, who brought us this education, now refuses employment to refugees who are forced to accept poor work. We need to stand up and challenge them on this issue. Zimbabweans are not going to exhaust social services; we are already educated and want to work and pay tax and have no intention to remain. So we need them to give us room, because when we come home to reconstruct the country, we need to have our skills still.
I am leading the ZCTU’s campaign on sanitary towels – which are not available to most women in Zimbabwe, and so this significantly interferes with their ability to work or lead productive lives. This is a very important issue. Zimbabweans are used to being very private about such issues as we do not speak of them easily in our culture, but now we must talk about them on the global stage. The average monthly salary is less than the cost of a pack of sanitary towels. So I am in the UK to make an agreement to receive sanitary towels and then we will be able to win the struggle. Even if we die, we will eventually win the struggle. Women are delivering babies at home because they cannot afford to go to hospital. Women are being sick at home because they have no money to go to hospital.
The Zimbabwean Diaspora needs to unite and stop this division between different groups. South Africans came into exile through the help of political organizations and institutions. Zimbabweans come into exile as individuals (some in search of greener pastures, some through organizations like the ZCTU), so we need to make more effort to unite across divisions. There needs to be one organization that centralizes all activities within the Diaspora.
The previous speaker spoke of HIV/AIDS, and the crisis of HIV/AIDS was one of the motivating factors behind our demonstration this week. There have been some shocking reports about declining rates and a reduction in the numbers of infections. But such reports are just not believable. 5 million people left Zimbabwe in the last few years, so of course the number of infected people has gone down! 3000 people still die each week. Anti-retrovirals are desperately needed; especially where women cannot refuse sex or demand a condom with their husband. We need anti-retrovirals as a start of engaging with this problem.
Remember – Coming together is a beginning,
Keeping together is a progress,
Staying together is a success.
Thabitha Khumalo - Formal (planned) presentation:
The history of migration is that of people’s struggle to survive and to prosper, to escape insecurity and poverty, and to move in response to opportunity. Migration is not the way to solve development problems, but properly managed it can deliver major benefits in terms of development and poverty reduction. The Diaspora and its members can be important agents of development. Governments have much to learn from a deeper engagement with the Diaspora, its members and constituent organisations. Helped by rapid and massive leaps forward in communications technology, these dispersed populations now have the capacity to exert far greater influence on their homelands than ever before. But the influence of these "new Diasporas" on their homelands depends on the resources they can mobilize, and this in turn depends on where they are located. The Diaspora should be involved in discussions on development strategies, voluntary remittance schemes and sustainable return.
It is estimated that about 5 million Zimbabweans have migrated to other countries in the past 7 years owing largely to the degenerating socio-economic and political developments. Others have however left purely to seek greener pastures. 75% of these migrants have settled in South Africa, the United Kingdom and Botswana. With the economy continuing to bleed this trend is set to worsen in the foreseeable future. These trends are however not confined to Zimbabwe alone. Diasporas have long been a feature of the world stage, but the acceleration of migration in the last 20 years both for economic betterment and to escape conflict and persecution – in short, to assure human security – has greatly expanded their reach and significance.
Protracted conflicts and widespread human rights abuse have generated substantial refugee flows to neighbouring territories or further afield to more affluent Western states have contributed to the formation of new Diaspora populations. But one of the most important influences Diasporas and other migrants can have on their countries of origin is to consider a necessary prior condition: that is, securing the connection between higher education in any society and the exercise of civil and political rights in that society.
Just as it is very hard to imagine sustainable and democratic development without promoting higher education, it is quite futile (I will argue) to deskill skilled human resources in a society where civil and political rights are systematically upheld. We often measure the value of higher education in instrumental terms: correlating numbers of graduate engineers with GDP performance, or investments in medical education with numbers of physicians produced. What I am concerned about now are the more intrinsic losses caused by the deskilling created by the lack of permits to work abroad, both as a private and a public good—benefits to the communities of those countries who employ our skilled manpower are beyond anyone’s imagination.
The above can be corrected and hopefully achieved if there is a connection between the Diasporas as agents for change and transformation and the institutions that are fighting for development in their homeland. Knowledge ownership goes to such fiercely contested issues as protection of intellectual property rights, and the exploitation of indigenous knowledge. But questions of knowledge ownership reach far beyond these familiar and important stakeholder rivalries. In the end, true development occurs when knowledge is owned—and operated—by communities, and by the women and men who form those communities. When we speak of promoting networks for change and development in Zimbabwe, we don’t only refer to remittances to our loved ones. The aspects of remittance transfers attenuate beneficial influence on the countries from which refugees come. First, the distribution of remittances is uneven, not all households receive them. We should instead advance the development of people, in their own communities. Development then needs to be seen in the light of a simple but difficult question: Who owns the knowledge?
The uneven distribution of remittances only creates change for a handful of people while the rest of the country is in abject poverty, limited evidence available suggests that these transfers are used at home for daily subsistence needs, health care, housing, and sometimes education. Paying off debt is also prominent, especially where unemployment is the order of the day, or when assets have been destroyed, sold off, or lost during conflict.
While refugees can make substantial contributions to the homeland while in Diaspora, they are never recognized as apart of the development instead, Governments of countries producing refugees have traditionally been suspicious of the loyalties of those who flee for obvious reasons. It is amazing how skilled labour is brutalized when it follows the jobs that are created in the global village. And alas our partners who are the Corporate World can invest and disinvest wily nilly and they are never penalized. This type of discrimination should be challenged without fear or favors because at the end of the day workers are paying the price of taking inferior jobs in the name of survival and at the same time they are made to lose their skills when they spent a number of years and a lot of limited financial resource trying to acquire the right skills to better themselves and their families.
The challenges we are facing now, to lobby and advocate systems of global governance that promote, support and sustain human development as issues of governance, are central to policy debates. Until recently, migration and development have formed separate policy fields, marked by differing approaches that hinder coordination and cooperation. For migration authorities in destination countries, the control of migration flows is the highest priority. By contrast, development agencies may fear that their objectives will be jeopardized if migration control is paramount. Can long-term goals for poverty reduction be achieved if short-term migration policy interests are to be met? Can partnership with developing countries be real if containing further migration is the principal migration policy goal?
While there may be good reasons to keep some policies separate, conflicting policies are costly and counter-productive. There is much potential in mutually supportive policies — in constructive activities and interventions that are common to both fields and which may have positive effects on poverty reduction, development, and prevention of violent conflicts. To fulfill this potential, Diasporas should be acknowledged as a development resource, and mutually supportive aid and migration policies should be encouraged. In particular, aid policies could take greater account of the impact of community developments, so as to foster complementary roles for the two kinds of flows to developing countries. The international migration and asylum regime could be made more supportive of these ends by:
- Maintaining flexible asylum and resettlement policies that relieve pressure on poor first asylum countries hosting refugees
- Allocating temporary work permits to workers from poor countries to meet labour shortages in developed countries
- Ensuring sensitive recruitment of highly skilled workers to avoid depleting developing countries of human capital
- introducing dual or flexible citizenship to allow migrants to return to home countries without prejudicing their right to stay in host countries
These measures should be taken in consultation with Governments, Labour and the Corporate rather than unilaterally. Steps could also be taken to involve all stakeholders in the discussion on migration, in order to develop an international migration regime that is comparable to the multilateral arrangements on trade and investment. The field of international migration might then have a better-defined constituency with the possibility of developing greater consensus than is currently the case.
Managing migration, particularly for poverty reduction, is beyond any single nation state. Effective and genuine partnerships must be established both bilaterally between migrant sending and migrant-receiving countries, and at the multilateral level.
Migration relates to many other issues including security concerns, HIV/AIDS, environmental degradation, international trade, agricultural subsidies, gender inequality and arms exports. Policies which seek to manage migration will have impacts in other areas, and vice-versa. Governments – individually and collectively – must do more to ensure that policies on related issues are coherent and support development.
Some of the major obstacles that need to be overcome include: government bureaucracy; government corruption; weak legal system; internal strife; lack of clarity about who in the homeland, government has the authority to approve or facilitate foreign investment; absence of pro-business government; lack of specific investment opportunities; homeland country hostilities with neighbouring countries; a weak financial system; too few economic incentives; problems with labour and/or labour laws; a poor physical infrastructure; level of economic development; lack of governments support for investment.No society will prosper in freedom without vigorous institutions. At the same time, no institutions will thrive where ordinary civil and political rights are suppressed.
Thank you.
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