H-NET BOOK REVIEW

Published by <H-Africa@h-net.msu.edu> March, 2000


Leon A. Bijlmakers, Mary T. Basset, David M. Sanders.
_Socioeconomic Stress, Health and Child Nutritional Status in
Zimbabwe at a Time of Economic Structural Adjustment: a Three
Year Longitudinal Study_.  Nordiska Afrikainstitutet Research
Report no. 105.  Uppsala: Nordiska Afrikainstitutet, 1998. 127
pp. Tables, graphs, notes, bibliography. $20.00 (paper),
ISBN 9-1710-6434-6.

Reviewed for H-Africa by Wolf Roder <Wolf.Roder@uc.edu>, Dept.
of Geography, University of Cincinnati, Cincinnati, OH 45221-0131


Health Effects of Structural Adjustment

In this major sociological study, the economic performance of
Zimbabwe is mirrored in the fate of individuals. It represents a
small part of a major ongoing research program on _The Political
and Social Context of Structural Adjustment in Sub-Saharan
Africa_, which the Nordic Africa Institute started in 1990. This
particular project was launched in May, 1993, and the results of
the first and second years were published in 1995 and 1996,
respectively. Thus, this is a report on continuing research.

The Zimbabwean economy fluctuated a great deal in the first ten
years after independence in 1980. GDP per capita and formal
sector earnings rose to a peak in the years immediately after
independence, then stabilized until about 1990. In the summer of
1991/92 the country experienced its worst drought in this
century, with consequent shortages in food grains, water, and
electricity.  In the same year the Economic Structural Adjustment
Program (ESAP) was instituted. This required the devaluation of
the Zimbabwean dollar (ZWD) against major currencies, curtailment
of subsidies to major food items, and dismissal of excess public
employees. This translates into inflation rates of around fifty
percent, and serious hardship for most rural and urban low income
earners. The need to decrease public expenditure forced a
significant reduction in per capita spending on health services.
Infant mortality, which had declined from pre-independence
levels, started to rise again. In the same period the government
felt forced to collect user fees for health services previously
obtained free.

The research project was designed to monitor and document changes
which took place during the ESAP process. The authors recognize
these were confounded by the economic effects of the drought, the
impact of the HIV/AIDS epidemic, and the general decline of
living conditions. In one rural and one urban site, the research
tried to monitor household changes in income and employment, in
food production and consumption, in the use of health care
services, in the benefits of external assistance, and in the
nutritional status of children under five. Relevant variables
were also measured at the health care facility level.

Research relied on a panel of three hundred households in an
urban area and another three hundred in a rural site, which were
interviewed in mid 1993, 1994, and 1995. Chitungwiza is a
suburban location about twenty miles from the capital to which
most of the employed persons commute. It is served by one
government hospital and four municipal clinics. Rural Murehwa
district is about 50 miles east of Harare in a communal farming
area. A government and a Catholic mission hospital and twelve
rural health centers are accessible to the area. Comprehensive
interviews with household members served as the main research
instruments. In addition, heights and weights of all children
five years of age or under were taken. Follow-up interviews
generally achieved participation rates between eighty and ninety
percent.

During the years of the study itself, Chitungwiza was affected by
the closure of a textile plant which made six thousand workers
unemployed.  The study was alsoaffected by particularly poor
rainfall in 1995. During the same period, and as a result of
ESAP, the government saw itself forced to dramatically increase
fees charged for health services at clinics and hospitals. At the
same time, the Ministry of Health found it increasingly difficult
to attract and retain doctors, nurses, and pharmacists or to
assure reliable supplies of medicines and equipment.

Household economies during the survey period diversified by
taking on additional, informal income producing activities.
Growing maize for their own consumption was practiced more
widely, yet self-sufficiency declined, partly on account of low
rainfall. At the same time households decreased their expenditure
on most items other than food. This included decreased
expenditure on medical care and education.

A reported decrease in illness in both study areas is unlikely to
represent real improved health, but rather a consequence of not
reporting illness for which no treatment was sought. Falling
outpatient attendance figures at the study clinics showed a
strong response to the increase in user fees. The research also
found strong evidence that home deliveries are on the increase,
and that prenatal clinic visits by pregnant women declined.
Neo-natal mortality rates increased. The nutritional status of
children and the extent of stunting increased. "In other words,
the children in the rural area had become more skinny between
1993 and 1994 and they remained skinny between 1994 and 1995"
(p. 106).

The authors examine comparisons between national poverty
statistics and household incomes at their research sites. They
detail the observed differences but conclude that Chitungwiza "is
not very different from some of the high-density suburbs of
Zimbabwe's major cities" and that Murehwa "appears fairly
representative of the communal lands"(p. 100).

This study is highly technical in design and execution. It is
excellently conceived and extremely well carried out. It provides
concrete data and answers to the questions it asks about the
effects of a Structural Adjustment Program on the well being of
ordinary people. It is an indispensable contribution to the
debate about the impacts of these macro-economic programs imposed
by the World Bank.

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