Leon A. Bijlmakers Sanders, Mary T. Basset, David M. Socioeconomic Stress, Health and Child Nutritional Status in Zimbabwe at a Time of Economic Structural Adjustment: a Three Year Longitudinal Study. Uppsala: Nordic Africa Institute, 1998. 127 pp. $20.00 (paper), ISBN 978-91-7106-434-9.
Reviewed by Wolf Roder (Dept. of Geography, University of Cincinnati, Cincinnati, OH 45221-0131)
Published on H-Africa (March, 2000)
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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Citation:
Wolf Roder. Review of Sanders, Leon A. Bijlmakers; Basset, Mary T.; M., David, Socioeconomic Stress, Health and Child Nutritional Status in Zimbabwe at a Time of Economic Structural Adjustment: a Three Year Longitudinal Study.
H-Africa, H-Net Reviews.
March, 2000.
URL: http://www.h-net.org/reviews/showrev.php?id=3941
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